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APPLICATION FOR SANITATION PERMIT �O <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 TION---- <br /> ll ---=------ -S--------------00-1--�------------------------------------------------------- <br /> : t ( - <br /> --- Phone---------------- - <br /> Owner's Name------------------ _&Y <br /> ------- <br /> Address--------------------------------------- ---------- - ------- <br /> Phone -- <br /> - <br /> Contractor's Name----------------Re ------------ <br /> -------- S- <br /> Installation will serve: Residence Apartment HouseCommercial ❑ Trailer Court E] Mote{ E] Other ❑ <br /> Number of living units: Number of bedrooms Number of baths I Lot size----_---1�2------x------'-2p--------------- �l <br /> Water Supply: Public system ❑ Community system ❑ Private Y, NAY <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 �S`[„ ` Not of ompartme tst_well <br /> --------------_Capacity from foundation Liquid depth------------------------- j <br /> ,-Cesspool: <br /> compartments <br /> y 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 <br /> --------------- _-------------.❑ Distance to nearest lot line---------------------__------------_-__-------_ <br /> F <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depfih---.---------•----------•------- <br /> r, <br /> �.Dis osa ield: Distance-from-nearestoweil-------------"_-Distance fr m 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 /> -Remodelin and/or repairing (descril�ej:--------------------------------------- -------------------------------------------------- <br /> - 4 t r 1 t o - -� ------ C h� - __i: -- -- ---------- /` � <br /> ------------------ _.t----- ---- l `C' �{ - - 4 <br /> t - ------------------------------------------- <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--- --------------------------------------------------------------- --------(Owner and/or Contractor) <br /> BY� �` - --- ------'-�`--------------------------------------------- (Title) ---------- <br /> �r <br />} (Plot plans, showin size.of lot, Iota+ion}of system in relation to welts, buildings, etc., must be filed with this application). <br /> I DEPARTMENT USE ONLY tt <br /> APPLICATION ACCEPTED BY-----------= -------------------- ---------------------------------------- DATE--- ----- ---- --- Z"J_ t- ----- <br /> REVIEWEDBY------------------------------------------------------ ------------------------- ---------- -------------------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED------------------k----------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> h <br /> Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------ --- ----- <br /> -------------- ---------------------------------------------- <br /> C� <br /> PERMIT No.-�--1�----�1--q <br /> ---. ISSUED------- ---------- -- - ----{Date) FINAL INSPECTION BY:---------- ---- - --------------------------------------------- <br /> Date---------------- <br /> <r ------------------------------------- <br /> SAN <br /> ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street v <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />