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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 /> -------------------------- <br /> JOB ADDRESS AND LOCATION------------- 3-4J---------- <br /> .E -- --------- Phone------------------------------------ <br /> Owner's <br /> ---------------------•-- -------- <br /> Owner s Name------ ---- ----------�--- ---- --- - <br /> --------------------------------------------------------------- <br /> Address <br /> --------------------------------- <br /> Address------ ---- -- <br /> fPhone------------------------------ <br /> Contractor's Name------------------------------------- -------•------------- ----- <br /> -------------------------------------------------------------------------- <br /> installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I ` <br /> Number of living units: ❑ F1Number of bedrooms <br /> Number of baths E] Lot size__.__--. T-0-x-tG Q------------------------`- <br /> Water Supply: Public system Community system ❑ Private ❑ <br /> a depth of 3 feet: Sand E] Gravel F1 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe V�Hardpan ❑ <br /> Character of soil to p <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sel AficTank: Distance from nearest well----` ---------Distance from foundation-_--__. 0 4-.Material--------- --- ------------ <br /> No. of compartments------------1------------ca Capacity ------------Size-----� - �------------Liquid depth-------------------------- <br /> - ; <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materia___---_- <br /> --------------- <br /> ❑ Size: Diameter---------------•-------•-------------Depth---------------------- -------------------- ------- <br /> Privy: Distance from nearest well_____________--_____-___-_-_____-__-_--__-_ <br /> ---_-Distance from nearest building------------------------------------------ <br /> El Distance to nearest lot line__________________________________-----_ <br /> Seepage Pit: Distance to nearest well--------- Distance f_rom foundation _____.---Distance to nearest lot line.--�0-------- <br /> ----.-Lining material.--- .-Size: Diameter-----_-�,-o ------------------ <br /> of pits___._.._-1_-_ --.Depth--- <br /> Number .f � <br /> Dis osal Field: Distance from nearest well `�_----.Distance from foundation_-_-J�6__--___-_-Distance to nearest lot lineSo____.- <br /> Number of lines-------------- -----------------Length of each line------- -/=------li--Width of trench_---_Z- ---------------- <br /> Type of filter material----- - ---------------Depth of filter material__-_---- - -_--- <br /> ----------------------------------------------------------------------•---------------------- <br /> Remodeling and/or repairing (describe}______________________________ <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 and regulations of the San Joaquin Local Health District. <br /> (Signed)` --- �- - K-- --------------------- -Owner and/or Contractor` <br /> ----- -------------------- -------------------- <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 ACCEPT ------------------------ <br /> DATE------ 5 ----------------------------- <br /> -- --- ------- <br /> REVIEWED BY----------- DATE-------6J' q—`- --- <br /> ------------------------- ------------------------------------------------------------ DATE <br /> PERMIT ISS ED------ - - <br /> DATE---------------------------------------------------- <br /> Alterations and/or recommendations---------------------- ------------------------------------------------ <br /> --------------- -- -----------•------------- ------------------------- •-----------••-----------•-----------••-------------------------------------------------------------------- <br /> --------------------------------- <br /> ---- ISSUED-_---�? .1,95Z-- Date FINAL INSPECTION BY:___---0 __to'[----- - -. Z "� <br /> PERMIT No.-_--___-_f- - { <br /> DDate--------------•---•--�-- __to'[ <br /> ate -- ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />