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,f <br /> .,�...�:.-.r 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. T <br /> JOB ADDRESS AND LOCATION-- -'-r�-'F.------------------------------------------------------------------------- <br /> '- <br /> Owner's Name------------- °'"------- - - ----- <br /> AddressPhone %- <br /> Contractors <br /> f <br /> Name4s: -----�- � �•! _�_A ------------------------------------------------------------- <br /> Installation will serve: Residence y Apartment Hous ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: 5M Number of bedrooms 4 Number of baths V Lot size________<10-_ -- - <br /> Water Supply: Public system ;K. Community system❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan E]k w <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 foundation--------------------Material____-------_-_----_-______________.____________. <br /> r ❑ No. of compartments--------------------------Capacity-----------------------Size-------------------------------Liquid depth----------------------- -- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-_-_ Lining material_______________________-_.____--___. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Priv Distance from nearest well-------------------------------------------------Distance from nearest building;,. <br /> El to nearest lot line_________________________________--------------- <br /> r <br /> 'Seepage Pit: Distance to nearest well_____Vin <br /> _____Distance from fourdation______ .__.Distance to nearest lot line----A/ <br /> �� Depth a <br /> Number of pits----------/---_-_ g material----�.�-d__Rc_�Size: Diameter------- - p -�-------------- <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,trench----------------------------------- <br /> Type of filter material__,________________-___._Depth of filter material-------------------_-__ <br /> Remodeling and/or repairing (describe)____________________ __.- <br /> --------------------------------------------- ----------------------------------------------------------------------------------------- <br /> --------------------------­­--------------------- -------------------------I...... ------- <br /> ------------------------ -- <br /> -- ---- -------- - -------------------------- ---- ----- ---- ----------- -- --- <br /> - ------ -- _ -- ---^ ___-________ ______ _ <br /> hereby certyI have p p prepared <br /> that work will be done in accordance with San Joaquin County <br /> ordinances, laws, and and' regulations San Joaquin Local Health District. <br /> ' --" <br /> (Signed) �`et-- ----------------------------------------------------------- (Owner and/or Contractor) <br /> k <br /> By:----------:------------------------------------- --------------------- -----------------------------------------------------------(Ti+le)-------- - - - =" '" --------F-------- <br /> 3 (Plot plans, showing size of lot, location of sy9tem in relation to wells, buildings, efc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------- ------- -- ---•-- ----- -------- -------------------------------------- DATE----------------------------- -------------- <br /> t REVIEWED BYrf%: -_ DATE — may <br /> BUILDING PERMIT ISSUED------------------------------------------ ------- -------- --- ------ DATE--- ----------- <br /> Alterations and/or recommendations:_______ _ <br /> t <br /> •-------------------------}------ - - - ` - <br /> . <br /> I-------------------------------------------------------- ----- -_-------- --------------_-------------------------------------------------------------------------- -------------------- <br /> _ -- -----t� ' ------- -- <br /> PERMIT No.__-- f <br /> ISSUED----__/{_-az_3------ -------------(Date) FINAL INSPECTION By --------------- ------ r►---------------- <br /> PERM IT <br /> -------------------------- -------------------------- <br /> SAN <br /> ---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T 130 South American Street <br /> ` Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />