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4_4 00 L� <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. 5491 <br /> JOB ADD <br /> KESS AND LOCATION - "` 'r <br /> Owners Name {` Phone <br /> Address----------�--t-�--- �------ -.1- .�-C ----- <br /> ---- -------------- <br /> ------------- <br /> Owner's <br /> F- - ------ ' <br /> contractor's Name. ,,,ae_p --------------------------------- -- - ---------- ------------------ Phone----------------------------------- <br /> ---------------------- - --- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel <br /> ❑ Other ❑ ' <br /> Number of living units: Number of bedrooms " Number of baths , osize------ <br /> `t Lot -------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private <br /> Character of soil to a depth of 3 feet: Sand`❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan [❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) v <br /> Septic Tank: Distance from .nearest well-------- fro rp foundation------ ___ � <br /> Yp`vl No. of compartments________� ___---___Ca acit ___-_�y?_� _____Sixe--______ - q A �j - <br /> Cesspool: Distance from nearest weft_________________Distance from foundation------------------- <br /> Lining <br /> material-de th_____--/ <br /> ❑ Size. Diameter----------------------------- -------Depth---------------------- ---------------------------- <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 /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter__-__.-----------------Depth--------------------------------- <br /> Disposal Field: a Distance-from nearest well______�AQ___.Distance from foundation-____yU,___--Distance,.to-nearest lot._line_-� -- <br /> Number of lines_______.__________ k. - <br /> __-____ Length of each line______ � dtlj o bench_________ d��'_________ <br /> Type of filter material___ Y--6epth of filter material____ _ ________ !� 20 <br /> Remod�,Ijng and/or repairing (describe)_____ __________ _______ <br /> ---------------- --------------------------- -- { <br /> - ----------------------------------------------------------------------------------------------------------------------------------------------------------- --- - - ------I-------------------------------------- <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 /> ( i9ne5 <br /> d) <br /> -- - - --- --- --------------------- ----------------------------------------- ----------------- ----------------- -(Owner and/or Contractor) <br /> Ry:------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ---------------- <br /> (Plot =� <br /> 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 /> W_REVIEWED BY - DATE------- - -- ------- <br /> BUILDING PERMIT ISSUED------------------------------- - DATE <br /> - - -- ------------------------------------ -- <br /> - ------------------------------------------------ <br /> A terations and/or recommendations_______________________________ <br /> -------------------------------------------------------I-------------------------------------------------------------------------=----- <br /> -------- ---- --------------------- <br /> PERMIT No:- d4', -_----- ISSUED__,r_;;2S_' ---_-__ -(Date) FINAL INSPECTION BY:_________________________ <br /> -------------------------------------- <br /> Date--------------------- --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> ES-9-2M 9-50 W-1639 Stockton, California o t <br />