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FOR OFFICE USE: <br /> ------------------------------------------------ <br /> ---------­------------------------ <br /> _______________________________________________----------------------------------- <br /> ___________________ APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------------------------------------------------- (Complete in Duplicate) Z of <br /> ---------- This Permit Expires i Year From Date Issued Date Issued _____ _______________( <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 OrdinanceL o. 54 <br /> JOB ADDRESS AND LO ATI ---Q.f._ "�C <br /> Owner's Name <br /> -------------------------------------- Phone.................................... <br /> Address. ---------- =- --------------•-----._----------------------------------------------------------------------------•----------------•-•---.. <br /> Contractor's tor's Name _ ------------------•----.. ------•---••-------- ------------_---------------•------ Phone.................................. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .4.. Number of bedrooms _ Number of baths Z.. Lot size <br /> Water Supply: Public system ❑ Community system ❑ Private Ire*Depth to Water Table'&.;:P ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8-"00ardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No R?`� New Construction: Yes ❑ No 8�FHANA: Yes ❑ No9�—` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se c nk ! Distance from nearest well_________________Distance from foundation--------------------Material____-__----____._______.___.-------......___.___. <br /> No. of compartments--------•------------...�ize--------------------------------Liquid depth--------------------------Capacity-•-------------------- <br /> p / <br /> Disposal field: Distance from nearest welL__`�._Distance from foundati n__�17---..__.._.Distance to nearest lot <br /> Number of lines-------- --Length of each line_` ............Width of trench.-A!--_----__--_________-___ <br /> Type of filter material�.r' _llf ��__Depth of filter material.. <br /> X_ length_._ �-�________________________ <br /> i / <br /> Seepage Pit: Distance to nearest well---`t0�-----Distance f om fo ndation-... ._.___.D' t rice to nearest lot <br /> Number of pits__-_f_____________Lining material_�+G. ------Size: Diameter___ �_..___-Depth-s94f ---....-----.--. <br /> Cesspool: Distance from nearest well.................Distance from foundation-------------------.Lining material..----------------------------------- <br /> 0 Size: Diameter--------------------------------------Depth----•--•--------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------_-------------- -_-----Distance from nearest building-_------__.______________---_---______... <br /> ❑ Distance to nearest lot line------ <br /> a <br /> Remodeling and/or repairing (describe):------ -------- t'7 ----- ---•---------------------••--------.----------._....--•-------- <br /> --=----------------- ------•-I-------------------•-------•--------------------------------------------------------------------- ----------------• ---------------------_ ---------------------- <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, State laws, and rules <br /> �and <br /> pregulations of the San Joaquin Local Health District. <br /> (Signed)--------------' �' �it----- ---------------------------( 7%r Contractor) <br /> By:--------------------------------•-------------••----- - --------i.. !y ----------------------(Tifle)....1'/. '------------- - <br /> (Plot plan, showing size of lot, location of sysfe n relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR D ART NT USE ONLY <br /> APPLICATION ACCEPTED B _____________QP--_---------------- _---_---.----.- <br /> REVIEWEDBY--------------------------•------------- -------------------- --------------- --------------------------------------------- DATE-----------_-------- <br /> BUILDING PERMIT ISSUED-_--•------------- ---------- ------------ ------ TE <br /> Alterations and/or recommendations: _ _._ _..__ <br /> ­----------------------------- <br /> --------- - ------------------ <br /> ---------------------------- --------- <br /> ---------------- -' <br /> ------ <br /> - <br /> ---------- -------------------- <br /> �-''•'---. �----- ----- -_"` f' � { ..�.f` ------- -- -•---- --------- <br /> _ <br /> FINALINSPECTION BY-------------------------------------------------- ------------- Date----------------------------------------------------------__----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9Th Strut <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-6Z ATLAS '�1 <br />