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y`L <br /> APPLICATION FOR SANITATION PERMIT Permit No. .�'Q_ <br /> Com lete inDuplicate) <br /> J { p Date Issued ------s---s-y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION___ _--J-�--------- ------------ <br /> ------ -------------------------------------------- Phone----------------------------------- <br /> ---------- --------------- <br /> 20��-6 <br /> ._ <br /> - ----------------------- <br /> S' S� <br /> �----- ---------------------� ---- - ---,-�-- } ���x'v - ----- <br /> Address- j j1 <br /> Contractor's Name f ' - Phone 7-- -d----------------- <br /> G. d <br /> Installation will serve: Residence [�r Apartment House ❑ Commercial ❑ 'Trailer}Court ❑ Motel ❑ Other ❑ <br /> Number of living units: /---- Number of bedrooms __o2-Njwmber of baths .__ Lot size __- '4 _--________ <br /> ------------ <br /> Water Supply: Public system 2--c-ommunity system ❑ Private i] Depth to Water Table ft. <br /> Character of soil to's depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam <br /> am © Clay ❑ Adobe Hardpan [❑ <br /> Previous Application Made: Yes ❑ No [r?—New Construction:' Yes [/?-`ro ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS <br /> t <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> jpjfi, ank: Distance from nearest well _______________Distance frem foundation--------------------Material __-------------_,--.__________________._.____._. <br /> No. of compartments------I------------------Size-------•------------------------Liquid depth--------------------------Capacity--- <br /> spo field: Distance from nearest well_________________Distance from foundation_________________._.Distance to nearest lot line----------- <br /> Number of lines-----------------------------------Length of each line---------------------------.-.Width of trench----------------------------------_ <br /> Type of filter material---'------ ---------------Depth of filter material----------------------- length________________________________________ <br /> Seepage Pit: Distance to nearest well----------------Distance from foundation--- s____._.Distance to nearest lot line_`S___-_____ <br /> Number of pits----/-------------Lining material Size: Diameter----• Depth----;2-4o <br /> l <br /> Cesspool: Distance from nearest well-----------I-----Distance from foundation--------------------Lining material-------------------------------------- <br /> El Size: Diameter-----: -----------------Depth_-------- ----f--------------------------------------Liquid Capacity-.--.---------------------gals. <br /> Privy: Distance from nearest well_I -------- ----------- ----- I-------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line ---------------------------------------------------------------•-------------------------•--------•---------------------------------- <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------- ----------------------------•------------------ <br /> -----------------------------------------------------------------------=••------------------------------------------=--------------------------- ------------------------------------------------------------------------ -- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St I s, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------- ----------- _______________________ _____- _{Ow rand or Contractor) <br /> ----------------- <br /> Ely:--- -- :1eZ---.. *- x.as( -----------------------------------------------(Title)----- <br /> (Plot plan, showi g size of lot, loce ionof sys m in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- - ------------- --------- - ,� ------------------------- DATE-- /+;� 1 ----------------------- <br /> REVIEWED BY--------------------------------------------- -------- ------------------- DATE <br /> ------------------------------------------------------------BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- <br /> Alterations and/or recommendations-------- --------- ----------r-----------------------------------------------------------------•-------•--------•----------------------------------------------- <br /> -----7----------------------------------------------------------------------------------- <br /> ------------------..._---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------•------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY----------------1/---'-I1rfj-u--I�-------------------- Date--- - --- --------6- ` -----------------------------------------_- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9--2M ; Revised W-2104 <br />