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1 <br /> Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) r <br /> Date Issued <br /> App <br /> lica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> I This application is made in compliance with County Ordinance No- 5K. & <br /> JOB ADDRESS AND[LOCATION . . ?_1.;)n ------ <br /> -------- ----------------------------------------------------------------- <br /> Owner's Name_ t!=`c�----- (� Phone <br /> Address......15---------- <br /> �f--------- ...._.... <br /> Contractor's Name- •-- - --------•--- ------------------------------------------------=------------------------/------------------------------ <br /> -V � � PhonT " � I <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/---- Number of bedrooms _;? _ Number of baths ---I---- Lot size ---_7�,f.!.An-v__________________ _ <br /> Water Supply: Public system 9�—C-t5tnmunity system ❑ Private ❑ Depth to Water Table _ ems__ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ . Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe k�—+�r�pan ❑ <br /> Previous Application Made: Yes ❑ No 4�­New Construction: Yes ❑ No E-- <br /> TYPE <br /> --TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tankc Distance from nearest well-----------------Distance from fourdation____.__:___�__-._.Material------.-----_--------_------------- ------------ <br /> I No. of compartments--------------------------Size---------------•----------------Liquid depth------------------------Capacity---------------------:. <br /> isposal Field: Distance from nearest we6--,?-Fs ux__Distance from foundation----l-0-.".-..Distance to nearest lot <br /> [ � Number of lines-----------/------ v Lengt.h.of,each,line-----2,5-----------_Width of trench_-- --_--.__-_______-. <br /> Type of filter m ---------------------- <br /> Depth of filter material Total length_._.___`--- ----------------------- <br /> I Seepage Pit: .. Disfance to nearest well. -ni.___-__Distance from fo6ndation____-7s7__ _•.Distance to nearest lot line-Z.O.---- <br /> Number of pits-------I-------------Lining Tate Size: Diameter_.34--------------Dept h... ��-------------------- {,V <br /> Cesspool: Distance from snearest well -__-___-_-:__Distance from foundation.-------------------Lining material-________-_____________.___-_._-- <br /> ' ❑ Size: Diarrieter----------------- - ----- ------Depth----------•---------------------------------- Liquid Capacity---------------------------gals. <br /> Privy: Distance from nearest well.,_--------------------------------------------Distance from nearest building------------------------------------------- <br /> ❑ Distance to nearest lot line..................... <br /> ------------------_----- <br /> Remodeling and/or repairing (describe):---------------------------------------------:-----------_t-----------------•-- - •---------.----••--------- ----•-••----•-••------------•--•---- <br /> Y , <br /> ------------------------- -------------•------------••-----------=------------------------------------------------=--------------•_...------•----------------------•--------------••------•---------- -----•--------------- <br /> I hereby.certify that I have prepared.this.application and that the-work wil!_be done.in accordance with San Joaquin County <br /> ordinances, St a laws, and,rules and regulations of the San.Joaquin Local Health District. <br /> Sined - - <br /> ( 9 )-- - - ----------- • • <br /> = ---------- -- --------------------------------- �nd or Contractor) <br /> -- <br /> -- <br /> BY� --- --- 4-11.11_ _-Z11-"`=-------------------------------------------------------------(Title)_d ` ---- -------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ( FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. ------------------------------------------- DATE-------- �` — ' <br /> REVIEWEDBY---------------------------------- - - -------------------------------------------------- --------------------------------- DATE------------------------------- <br /> BUILDING PERMIT ISSUED----------- i------ -- ------------------------------- DATE---------------------------------------------------------- <br /> - -- ----------------------------------------- <br /> Alterationsand/or recommendations--- ------ ---------------------- ---------- - -----------------------------•---------------------------•-•----------------•---------•--------- <br /> -1 <br /> ---------------- <br /> -----•-•--•-----------------------------------------------r <br /> ---------------•-•------------------------- -------------- -------------------..----------------- ------------------------------------------------------ ----------------------------------------------------------------- <br /> - ---------------- Date...-------- -- ------------ <br /> FINAL INSPECTION BY:-------- -=-�--- -�--------------- -- - - �------fes----• --•- ........-------�• •-- <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Ameriaen 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 145446 ATWptlD 12-54 <br /> t <br />