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:a <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION---- -------�`------4P_Z:e1---- -- --------------------=---------------------------------------------------------------- <br /> --------------- <br /> -- <br /> Owner"s'Name= -------- - ------------------------- ----------------------------- Phone------------------------------------ <br /> ----- <br /> Address---------1Q' fir- -t ---; ; ---------------------------------------------------------------------------------------------------- <br /> v , <br /> Contractor's Name-------------- �-------------- -`r _ Phone ~a <br /> ------=----------------------- ------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court'❑ Motel ❑ Other rat-e� <br /> Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size-------1�_' l _ --____�_________________ <br /> Water Supply: Public system [Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ Adobe U1 Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic +ank or cesspool permitted if public sewer is available within 200 feet.) <br /> 6 <br /> Septic Tank: Distance from nearest'well----AV—Distance from foundation_______10-------Material__________ _ -_ ____ _____-. <br /> No. of compartments--------- _____Capacity____/,P.&--0------Size--- _ <br /> -�- - -_L•squid depth----------- - <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- <br /> El <br /> _-__________-_______ _____________.❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- 1 <br /> Privy: distance from nearest well-------------------------------------------------Distance from nearest building----_-------------------------------_____. <br /> ❑ Distance to nearest lot line_______________________________________________ <br /> Seepage Pit: Distance,to nearest,well ________-------------Distance from foundation___________________Distance to nearest lot line----------------- <br /> d:�:...�- .- <br /> ❑ Number of pits----------------------Lining material---------___--_`--=---Size:`Diameter----.....-_._____..__.. --------------------------------- <br /> Disposal Field: Distance from nearest well---- ______-Distance from foundation______1_Q________Distance to nearest lot line--- ____--__INA __. <br /> d"A Number of lines------------__t______-___�-----ll__Length of each line_________f_ Q_ _ <br /> _ -_ -_.Width of trench------?:-1_0 --------- <br /> _.r_____-- _______ <br /> Type of filter material_/Y%+-_ -___! _Depth of filter material---_____f <br /> Remodeling Iand/or repairing (describe):---------- -------'o---A;_4a__-_-- - }- ------ 4- �------- ir _42. o------------ <br /> ----- -------------- --------------------------------------- <br /> -------------------- <br /> ------------------------------------------------------------------------------------------------------------- � -------------------------------------------------- <br /> --------------------------------- <br /> I hereby certify that I have prepared this application and'+hat the work will be done in accordance with San Joaquin County <br /> ordinances, State laws and rules ari&regulations of the San Joaquin Local Health'District. <br /> �------------------------------- <br /> (Signed)----------"---j----- -1(--- _ [Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------ -----------------------------------------------------(Title)---------------------- - - .. <br /> - - ----------------------------------- <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 /> -- - ---- --------------------------ice---�------ -------- .. - --'� <br /> REVIEWEDBY--.--:-_:-•---------------- ---- _ -----�--------------------------------------------------------------------- DATE------------------- ----------------------- ----------- <br /> --BUiLDI-NG PERMIT ISSUE] ------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alferafionsand/or4ecommendations:_----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------- { <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------•---------••-------.-----------------•-------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------- ------------•--------------------------- <br /> ------------------------------------------------------- <br /> ---------------------------------------------------------------------------- <br /> --•--------------------------------------------------------- - <br /> ------------------------------------------------------------- <br /> PERMIT Nq _ __-- ISSUED----------- --- - '}7--(Date) FINAL INSPECTION BY:_-- ----- <br /> c ----------------- <br /> ------------------------- <br /> Date------------���� r_----------------------------------------- { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street I <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />