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APPLICATION FOR SANITATION PERMIT <br /> 4 2 I (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 Count Ordinance No 549 <br /> JOB ADDRESS AND L ATION___________p.- 5 <br /> - -------------------------�� �.�------------------------------------------------------------ - - <br /> Owner's Name-------------- _ r <br /> C �� - Phone <br /> Address —'� - ------- `--`'-- <br /> Contractor's Name------------------------------ -------------------------- Phone----------------------------------- <br /> er will serve: Residence Apartment House ❑ mmercial Trailer Court ❑ Motel ❑ Ot er ❑ <br /> Number of living units: [ Number of bedrooms $ Number baths Lot size------------dVCr---_ ___ C f <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 s1wer is available within 200 feet.) <br /> Septic ank: Distance from nearest well__•_. _ Distance fio o eati n_____7 ___.Mater#.' <br /> _ Q)'1..1�_(' ________________• ` <br /> No. of compartments-__-_-_-..__�.___Ca acit __=__�W � ize___..____ � <br /> p Y <br /> Cesspool: Distance from nearest well-----------------Distance from foun ation_---.._--____-____.Lining material•-._________-____-__-__.-.__._-_-__--. <br /> ❑ Size: Diameter--------------------------------------Dept h--------------------------------------------------- <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.------_-- --------Linings material-----------------------Size- Diametef........................Depth------------------------------_r <br /> �,Dispos Field: Distance from nearest well___ ._..Distance from foundation.__ _(__---Distance to nearest lot line <br /> Number of lines---____._________________ Length of each line___--___,� _ Width of trench-._______2 --__-.-_________- <br /> Type of filter material..... Q_L� �.___.Depth of filter material......... _..___-_.•_ <br /> `Remodeling and/or repairing (describe):--------•------------.........................................................................•--........................................ <br /> ---------------------- <br /> ---------------------------------------------------------------..................................,----------------------------------...............................................................................-...-...... <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 ruleVad egulationsof the San Joaquin Local Health District.- <br /> r� ---- - ------ - --- •-•----------- -----(Owner(Signed)-----+l ( rand/or Contractor) <br /> By:------•-----•---••--- --------------------------------------------------------------------------------------- ---------(Title)---------------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must bb filed with this application). <br /> FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY._._ _ _ DATE__-___-_•_____ I Z- <br /> REVIEWED BY-- -_------------- ---- ----------------- DATE--- 1-�---- ---------------------•------- <br /> BUILDING PERMIT ISSUED- --------------------------- ------ DATE------------- <br /> Alterations and/or recommendations--------------------------------------------------------------------------------- <br /> ---•---------•-----------------------------------•------------------------------••---------•-------•----------------------- ----------------------------------------­----------------- ------- --------------- <br /> -- -------------•---•-------------•----------------------.------------------------------------------------------------------------------------------------------•--•••----.._--- <br /> - ---------------------------------- ---------------------------------------------------------------------------------------------------------- -- --- ------ .............................. <br /> -----------------------------------------------------............................................................••. -- --- • -••---•--•------•----•-•------- <br /> PERMIT No------1p_-_.L---------. ISSUED--. `.1._ S� ,S'_0.._.__..(Date) FINAL INSPECTION BY:-.,........ ___-•_---..-___. <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 />