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1y2s�( <br /> � Rr <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. 549. • <br /> JOB ADDRESS AND LO �4d <br /> CATION------ 1 ,---- 1 1-1-----15-1--1---------------------------------------------------------------------------------------- <br /> Owner's Name Qd'.... ! "iia - Phone ......................... <br /> Address----------------------- ........ <br /> Contractor's Name ----------------------------------- ---•----------_--------- Phone-------------------------------- - <br /> Installation will serve: Residence RI Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-❑ <br /> Number of living units: [J] Number of bedrooms Q] Number of baths [Z] Lot size....... ---4 ---------------------------- <br /> Wafer <br /> -_. -__-._-_ •_•--.-.._ <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 sewvis available within 200 feet.) <br /> _ a <br /> Septic Tank: Distance from nearest well.__y•__►a---we____Distsance from foundation_____�'� _Materral-�'_0_-n C.!' �C , . <br /> P9No. of compartments-----------2 -_-_.-___Capacity/_,OS.—O.�_Size_3 z.v.$--".X-%I'*;t'Liquid depth...... ______------. . <br /> Cesspool: Distance from nearest well---_-_--__-_•--••Distance from foundation.-_._________________Lining material....---------------------------------- <br /> El <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 /> Disposa) Field: Distance from nearest well.W W'�'{�_Distance from foundation.-.-___Distance to°nearest lot r1' _Number of lines_,._._.__.._Z'-___ �� Length of each line____ .____�_b Width of trench__.__.. - <br /> Type of filter material.....,_ ---------_--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 wilf be,done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> , n <br /> (Signed)---- -------- '= ------------_--_------_------- <br /> ------------•-•-- --------------(Owner and/or Contractor) <br /> By:.....---------•---------------------------------------- ------------------------------------------------------------------------(Title) - ------------------------------------ <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 <br /> --------------------- DATE------ - <br /> REVIEWEDBY-------------------------------------- s-------` '-_--------------------------=-'----------------­----­--------...... DATE-------------------------------- ..................... <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------- -----------------•- <br /> Alterations and/or recommendations------------------------------------------------------------------------------•----------------------•--------------------- - <br /> -------------------------------------------------------------------•------------------------------------•...................------------------------------------------------------•---------------------------------•--- <br /> ------------------------------------------------------------ 6 _ <br /> ---------------------------------------------------------•---------------------------------------------------------------------------------------------•----------••----•---------•----------•-.---------------------------- <br /> PERMIT No..�a.Q__pp_.._.._.._ ISSUED.___�..'"__J�' ..............(Date) FINAL INSPECTION BY:.........W..iK <br /> Date------------•---- ./. ' 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />