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AAPPLICATION FOR SANITATION PERMIT 7Ae <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 finance o- 549. t <br /> JOB ADDRESS MDLO TIO r " <br /> Owner's Name f�4 a Phone------- --------------------- <br /> Address----z---a...i------ - -- ---------------------- ----- - -------= '1 -------------.--------------------------------------------------------------------------------------------------- <br /> Contractor's Name---- ---- G - °---------------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ '`Trailer Court ❑o Motel E] Other F1Number of living units: umber of bedrooms Number of baths [1] Lot size___Q__Q _________________________ <br /> Water Supply: Publics stem Community system ❑ Private ❑ <br /> Y <br /> Character of soil to a depth of 3 feet: Sand ❑ +Gravel ❑ Sandy Loam ❑ ,Clay Loam ❑ Clay ❑ Adobeardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS- __ W <br /> (No septic tank or cesspool permitted if pt)blic sewer is availabli within 200 feet.) <br /> Septic ank: Distance from nearest well Q Q_Distance fro cfoundation_____I_ __ ter _'__ � k <br /> �, f---------- <br /> No. of compartments_________________Capacity_ I._Q__9_____Size_______________ __Liquid depth__________________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> 171 <br /> _________________________.7,!�4 <br /> ❑ Size: Diameter--------------------------------------Depth-------------------------------------------------,_ <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> 171 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 /> Dispos Field: Distance from nearest well__/-/_`3____.Distance from foundation____ 3_____-Distance to nearest lot liI�Jr__S______ <br /> Number of lines___________ _'____ _ ____ __ _Length of each line___________ Width of trench______Ae_`-'_______________ <br /> T <br /> Type of filter materia .�G(, Depth of filter material_________ <br /> -------- <br /> J <br /> R odeling and/or repairing (describe):__ ti <br /> �.a X11'- l -------- <br /> ------------------------------- <br /> ---- <br /> �'t„ - ------ <br /> ------------------ - -- -- ------------------ ----- - --- --------- ------------ <br /> -------------- ----�---------- ------ - ----------------------------------------------------------------------------------------------------- I <br /> I hereby certify that I have prepay this apphcat on and that t e 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) 1� r = --' px°-----------------------------------------------------------------------------------------------------(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------------------------------------------ ------------------ �DATE---------------% ------------------- <br /> REVIEWEDBY--------------------------------------------------------------- - ------------------------------------ DATE--------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations--------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------- <br /> f ____------ ISSUED--- ---------- /�1l-------------(Date) FINAL INSPECTION BY:--------11 � -- -.- ------_--------- <br /> PERMIT No-7a---- �3 ,[__ -------- -� ---=�- �° `-- <br /> Date----------------------- ---- - 1---------------------- <br /> 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />