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IL <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 compliancewithCounty Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION --0 <br /> / ---------------- <br /> Owner's Name - --- ------ F- - - ---- --------------------------------------------- Phone------------------------------------- <br /> Address ------ - ------ <br /> ----- ----- ------------------------------------------------------------------------------------- <br /> L <br /> Contractor's Mame-- ----- --- -- <br /> Installation <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: / Number of bedrooms ;Z_ Number of baths / Lot size__) ! __ `----------- ---------- <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.) <br /> Septic Tank: Distance from nearest-well________ _____Distance from foundai-ion______�-7___-__--_--.Material-__ <br /> ✓��jl No. of com artments______ <br /> P _�;L-----------CapacitY---4ft'7-47-------Size--�-_4-A-74---:---Liquid depth L-V�2„------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation______________.___-Lining material--------------------------______.____ <br /> ❑ Size: Diameter-------------------------------------Depth------------------------------------------------ <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> 0 Distance to nearest lot line______________________________________________ <br /> 0 <br /> Seep Pit: Distance to nearest well____ ____Distance rom o ndation____ ------Distari e to nearest lot line____ ' _ -- <br /> Number of pits-------/------------Lining' material_ Size: Diameter -------Depth__._- ---------------- <br /> -Disposal <br /> _____________- + <br /> —Dis osal Field: Distance from nearest well_ `�---Distance from foundation____ � &r <br /> p ----- -------� �-__--_.Distance to nearest lot line_____ __________ <br /> Number of lines__________ _� ___ __ .__Length of each line____-- O � Width of trench___,t_q/-��______ <br /> -------- ------------ <br /> Type of filter material <br /> ------ of filter material_____��__-------_._ <br /> Remodelingand/or repairing (describe)----------------------------------------------------•-------------------------- ------------------------------------------------------------------------ <br /> --------------------------------I-------------------------------------------------------------------------------- <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) t , � 1 1�_____-- Ca► -- ----------------------------------------------------------------- d/or Contractor) <br /> BY� ------------------ (Title) -�-------7"---------------------- <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- - �`-rl <br /> •------------------------ <br /> REVIEWEDBY------------------------------------------------------------------------------------- -----------------------------------------DATE <br /> BUILDING PERMIT ISSUED---------------------------------`------ ------------------------------------------------------------- DATE. <br /> Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- <br /> -------------------------------- ;----------------------------------------------------------------------------------------------------------------------------•--------------------------------------------•------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------- ----------------=-------------------- - -- <br /> ---------------------- <br /> PERMIT No......... ----- ISSUED----- 1.7-� � <br /> _____-' <br /> --- -- - ---------(Date) FINAL INSPECTION BY:------- _ --------------------------------- <br /> Date------------------ <br /> ------------------ ----------Date------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />