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APPLICATION FOR SANITATION PERMIT' Permit No. <br /> (Complete in Duplicate) <br /> Date Issued�Adpl <br /> Application i 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. 5 <br /> JOB ADDRESS AND(LOCATION------- --------------------------------------------------------------------- <br /> . ...... ------- <br /> --------- ---- <br /> Owner's Name-----/-------- - X),ee&41--------- ----- -- --- ----------------------------------------------------------------- ---------------------- <br /> Z_ - r <br /> Address-------1. 39----------2310-1-------- <br /> --------------------------------------------------------- <br /> ----- --- il---------------------------------------------------------- Phone------------------------------------- <br /> Contractor's Name-------------/�_ �_ <br /> Installation will serve: Residence tZ Apartment House ❑ Commercial E] -Trailer Court [j Motel [] Other E] <br /> Number of living units: A-_ Number of bedrooms Number of bath's X__ Lot size ------ ---------------------- <br /> Wafer Supply: Public system Community system E] "Private [j Depfh,to Wafer Table/;/ , ft. <br /> Character of soil to a depth of 3 feet: Sand [-] Gravel 0 Sandy Loam E] Clay Loam [] Clay Cj Aclobex Hardpan 0 <br /> Previous Application Made: Yes E] No New Construction- Yes [] N <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank; D;S'fance from nearest well--_-------------Distance Distance from foundation----------------------lvlaferia#-------------------------r----------------------Ne <br /> ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------- --------.-Capacity-------- ------ <br /> Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line-._---_----_-.- <br /> ❑ <br /> ine----------------- <br /> El Number of lines-----------------------------------Length of each line-----_--------------- -------Width of french----------------------------------- <br /> Type of filter material------ -------- ---------Depth of filter material-----------------------Total length-_.-______________..____..__.-._______.__ v <br /> Seepage <br /> ength------------------------------------------ <br /> Seepage Pit: Distance to nearest well- N6�".___Disfance from foundation___ ___ _/._.D'isfance to nearest ]of line----- ----------- <br /> Number of pits..-.------/-------Lining maferial-18,114-el------Size: Diamefer_­aAW�------Depfh___.,aP__S-------------- ­_ I <br /> ss ool% Distance from nearest well-----------------Distance from foundation--------------------Lining material_-.----___--------------------._.___-. <br /> -rt Size: Diameter----_-------------------------------Depth------------------------------------------------.-.-L;quid Capacity----------------------------gals, <br /> Privy; Distance from nearest well--_--___- ----- ------------------------------Distance from nearest buildin❑ g.----------------------------------------- <br /> Distance to nearest lot line---------------------------------------------------------- <br /> Remodelingand/or repairing {describe):-------------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ---------------------••---------•---•--------------------- -------------------------------------------------------------------------------------------------------------------------------------------•---------------- <br /> -------------------------------------------­.­.............. ..................­------------------------------------------------------------1-------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------7------------------------------------------------ <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 and regulations of the San Joaquin Local Health District. <br /> [Signed)..-.-- ­ ------------------------------------------------------------------------------------- ------------- (0 r and/or Contractor) <br /> ---- --------------- Owner <br /> WA -—-------------------------------------------------- <br /> By:-------------- ---------- <br /> (Plot plan, showing size of lot, loca+ior <br /> of Ste in relation to wells, buildings, 'etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> BY---- <br /> BY---- DATE------ ----------- --- - <br /> -- ------ <br /> REVIEWEDBY------------------------------------ ---------------------------------------------------------- ------------•--- DATE--- <br /> BUILDING PERMIT ISSUED--------------------------------- ---------------------------•------------------•------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommend afions:----------- ---- --------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------­­--------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- ----- ------------------------------------------- ------------------------------------------------------------­--------------------------------------- <br /> ---------------------------------------------------------------------------------------------- --------------------------------------------------------------------Dated ---------------------------------------------------------- <br /> ---------------------------------------------------------------------- -- -------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:----------- ---- -------------------------- -_ <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 JO.52 Revised W-2100 <br /> ow k,/ <br />