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APPLICATION FOR SANITATION PERMIT <br /> r (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 Ordinanc No. 549. <br /> JOB ADDRESS AND ATIO __ _� > *� '�`-- -------------------------------------------------------------- <br /> Owner's Name----------- --------r -- ----x-------- <br /> - ------- -- <br /> Phone__-3 - --- <br /> Address____________ <br /> �- -------------------- � <br /> /- R_ <br /> Contractor's Name-------- --- - -1_-'G'�+- -------------------- Phone=� ------• ' 1 <br /> Installation will serve: Residence Apartment H use Commercial Trailer Court E] Motel [- Other E] <br /> Number of living units: [' Number of bedrooms? Number of baths V Lot ------------------------W <br /> ! Water Supply: Public syste�$3feet: <br /> Community system El Private E]Character of soil tc a depth Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ AdobeX Hardpan ❑ 4 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> i <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' i <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material---------------------------------_-----_----_, <br /> No. of compartments Capacity --Size------------------------_-____--Liquid depth-------------------------- ry <br /> ❑ p p Y <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________________ <br /> Size: Diameter--------------------------------- <br /> ❑ -----Depth---------------------------------------------------- <br /> d <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----__.__.._______________________----. <br /> ❑ Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well-------! ---------Distance fr f u ation____ --.Dista c to nearest lot line__ _____.--._ <br /> Number of pits______f------------Lining material- W76NSize: Diameter-_37 ________________ <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line___________-_____ <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter material_____ _________________D,pth of filter material------------------------ <br /> 1, <br /> Remodeling and/or repairing (describe): -1ri_fiy� ------- ------------------- <br /> ------------------------------------------------------------------------------------- --- ------ -------- ------------ <br /> ---------------- <br /> --------------------------------------------------------------------------------------------------------------------- <br /> - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, 5ta s, od rule a d regulations of the San Joaquin Local Health District. <br /> (Signed)------ ----- -- -- ---�"i-------------------------------------------------- ( w er and/or Contractor) <br /> BY:---------------------------------------- ------------------------------------------------------------------------------------- Title ------- _i -- <br /> (Plot <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 BYq1 �DA ---- <br /> T6 <br /> - <br /> REVIEWED BY DATE-- <br /> --------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations-------------------------------------------- --- ---------------------------------------------------------------------•---------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- <br /> ------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------7----------------- <br /> ----------------------------------------------------------------------------- - ------------------------------- ------------------- ------------------------------------- <br /> - ------------------------I----`--/-------- <br /> q ---- ISSUED--- S_�_ --�5�---- ----------(Date} FINAL INSPECTION BY:_--------- v-_ L ------------------------- <br /> ERMlT No,______ `- __-- <br /> -, Date--------------- - - --=----�- -=-------- ---- ------------------------ <br /> SAN <br /> ---- ---- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I v 130 South American Street <br /> Stockton, California <br /> € '°ES_9--2M 9-50 W=1639 <br />