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d ' <br /> APPLICATION FOR SANITATION PERMIT_ - <br /> ' (Complete in Duplicate) c <br /> Application is hereby made to the San Joaquin Locai 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____-----.�'a__3-3------------ -_c_ r '� <br /> Owner's Name----------------- --------- G G h..-�--- � -------- Phone------------------------------------ <br /> -------------- -----------------A---------- <br /> iI---------!YC 6?f-/--- C r_S-fq---`------------------------------------------------------------------- <br /> Contractor's Name----------------------------------- ---------- <br /> ------------------------------------------------------ Phone--------------- -------------- <br /> --------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: [6 Number.of bedrooms ® Number of baths 0� Lot size------_4; XJ-Q-P------------------------------- <br /> Water Supply: Public system E Community system [I Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam ❑ Clay ❑ Adobe ] Hardpan [� W <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: W <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------.Distance from foundation-------------------Material------------------------------------------------- <br /> T-1 No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth--------------------------- <br /> 'Cesspool: Distance from nearest well---------------_Distance from foundation--------------------Lining material___---------_-------___-_------______. <br /> ❑ Size: Diameter--------------------------------------Depth--------t-------------------------------------=---- <br /> privy; Distance from nearest well----------------------------------------_--------Distance from nearest building--------_-------___-----___-_--_---_____. <br /> dDistance to nearest lot line------------------------------------------------ <br /> Seepage <br /> ------------------ _____-__---- -----_Seepage Pit: Distance to nearest well---____---------------Distance from foundation-------------------.Distance to nearest lot line --- ----------- <br /> 0 Number of pits----------------------Lining material------------------------Size: Diameter--------------------- Depth--------------------------- <br /> .Disposal Field: Distance from nearest well-----------------.Distance from foundation--- ST__--__Distance to nearest.lot/line----- ------- <br /> [y Number of lines--------------- Length of each line------/-- _ --------Width of trench----- -7 -------------------- <br /> Type of filter material___._ Y- -Depth of filter material-_-_-I _________.._ <br /> ------ t t - <br /> - ----------------------------------------------- <br /> "Remodeling and/or repairing (describe):----=----------------------------------- ------- F <br /> -------------------------------- <br /> - --------- <br /> � � LII <br /> / /fin/ ' <br /> ------------------------- ------------------------------------------------------------------------------------------------------•------------------- <br /> I h6reby 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)---------------------------------------- --------------------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> Title <br /> (Plot plans, showing 'size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------- .__ --------------------------------------- DATE <br /> REVIEWEDBY-------------------------------------------------------------------- --------------------------------------=------------------ DATE---------- --------------- , / ---=-------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- ------ DATE------------------- <br /> and/or recommendations-------------------------------------------------------------------- --------------------------------------------------------------------------------------- <br /> ------------------------------•-------------------------------------------------------------- ------•------------------------------------------- <br /> -----------------------------•------- ------------------------- --------------------------------------- ------------------------- <br /> ---------------------•------------------------------------------------------------------------------------------------------- <br /> - ------------------------------------------'-- ------------------------ <br /> PERMIT <br /> --------------------- <br /> - - ------------- -- - <br /> - /01-' <br /> PERMIT No.___�.__�--3---__-- ISSUED---_--r�-.�'-�---�-�-Y---------(Date) FINAL INSPECTION BY: ----------------------- <br /> Date------------- 1 � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br /> l <br />