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APPLICATION FOR SANITATION PERMIT <br /> ,.,� Permit No <br /> (Complete in Duplicate) Date Issued <br /> -A--- <br /> Irl Sp licafion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T application is made in compliance with County Ordinance No. 549. <br /> q41 <br /> ADDRESS AND LOCATIr <br /> JOB A e7---f------- -- - ----------------------- --------2Z1 -------- ---------- <br /> Owner's Name----------- ----------- --•-•------------------ ----------------------------------------------------------- Phone------------------------------------ <br /> Address-------------------------------- - - --- ----- ---- - - --- --------%# <br /> / ----! --— -- ----------------------------------------------------------------------------I--------------I......... <br /> Contractor's Name-----7---------------- -- ------ - - ------------------------------------------------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence ��Apartment House [] Commercial [] Trailer Court 0 Motel [] Other 0 <br /> Number of living units: Number of bedrooms -Nf- - Number of baths Lot size,----� -- --------- ----—--------------- <br /> Water Supply: Public system ❑ Community system 2`4Private E] Depth to Wafer Table .-;VVff" <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam [] Clay [] Adobe En--11'a"rdpan 0 <br /> Previous Application Made: Yes E] No grNew Construction: Yes §D,-ITo El FHA/VA: Yes [G]�I<lo El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank- Distance from nearest w4/�0,)fjerDisfance-ff nclafion-----14*9--------Mateial------ <br /> rpm ou <br /> No, of compartments_-__- --------------Size--- -___Liquid depth-_-;0�4 ---------capacity----J9 <br /> Disposal Field; Distance from nearest well,,nO Distance from foundafion-,,-*P---------Distance to nearest lot liqe--- <br /> Number of lines--------1�&.- ------Angth of each of trench--------:Z7­34 ;W;� <br /> Z------- ------------- <br /> Type of filter materia Depth of filter material----- ----Total length------- --- ----------------------------- <br /> Seepa. Distance to nearest VeII-12Zo--A-*0*'-bisfance from fo/dafion--,, .,_-.Distant to nearest lot line--.%.f ------- <br /> � <br /> Number of pits. <br /> Lining material-. size: Diameter--- ---Depfh---.A-A::-------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material------------------------------------- <br /> El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. <br /> gals. <br /> Privy: Distance from nearest well--------------------------- ---------------------Distance from nearest building______-______________________________-___. <br /> ❑ <br /> uilding------------------------------------------ <br /> 171 Distance to nearest lot line--------- ---------- ----- -------------------- -------- <br /> Remodeling and/or repairing {describe):-------------- ------------- ----------------------- <br /> -------------------------------------q....... Z--,------ --------- ------------- -- --- <br /> ------------------------------------------------------------------------------------------------------ <br /> ----------------------- S�-�-------------------------------------------------------------------------------------------------- <br /> - ------- ---1-4- - - ------------- <br /> ------------------- ------------------------------------------- --------------I------------..------------------------------------------------I----- -------------•------------------------------------------------ <br /> I <br /> ------------I--------I--------------------------------------- <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, State laws, and ruland regulations of ' e San Joa .uin Local Health Dlst�lcf. <br /> (Signed)----------------- ------ ---------- -- --------------- (G*"aF=wmdA= Confracfor) <br /> By:---------------------------------------------------- l--------------------(Title)--------- ---- - - ----- --- <br /> -----I- -------- <br /> (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can be place on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY4------------------------------------------------------------------------ DATE 0 ------------ -------- <br /> REVIEWEDBY----------------------------------------- - - --------- ---------------------------------------------------------------------- DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> Atferations and/or recommendaf ions:----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------I------------------------------- <br /> ----------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- --------------- - ------------------------------------ --------------------------------------------------------------------------------- <br /> ------6K-d--�------------------------------ D <br /> FINAL INSPECTION BY--------- ------- ------- ----- afe------------------------------ ------------------------------------------------- <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 /> ES-9-2M Revised 1-57 FYM <br />