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d- <br /> �� iL <br /> APPLICATION FOR SANITATION PERMIT <br /> I (Complete in Duplicate) <br /> f - <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 /> -------�� -_!_�---------- --� - ----------------------------------------- <br /> JOB <br /> - ------------------------------- <br /> JOB ADDRESS AND LOCATION------s-------- <br /> Owner's <br /> _____Owner's Name----------------------- . . ---- ----- ----- ---------- ------------------------------ Phone - - <br /> -------- <br /> ---------------------------- <br /> Address------------------------ <br /> ------------------------------'----Address-----------------------• --------- <br /> Contractor's Name �--------------- --------- -------h--o--n-e--------- <br /> '] <br /> -------- <br /> ', � - - 0- <br /> Installation will serve: Residence 19 -Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -14 Number of bedrooms Number of baths Ij . Lot size------------------------------ <br /> Water Supply: Public system Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand F1 Gravel El Sandy Loam E] Clay Loam E] Clay C] Adobe Hardpan L) <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 /> ❑ --Capacity-----------------------Size--------------------------------Liquid depth------------------------ <br /> No. of compartments________________________ "- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-______________________ <br /> ------------ <br /> ❑ Size: Diameter-------------------------------------Depth--------------------- -------------------'------- <br /> _______:._Distance from nearest building --------- <br /> Privy: Distance from nearest well--------- -------------------------- ------------- ------------- - . <br /> ❑ Distance to.nearest lot lir}p-__ � � d <br /> i Seepage Pit: Distance to nearest well______________________Distance from founclation/________.Distance to nearest lot line___- __�__� <br /> Number of pits________-1----__--Lining material_-_ � L Size: Diameter.-__JV`-------Depth;"'___--#as---- <br /> Disposal Field: Distance from nearest well___________-____Distance from foundation____________________Disnte to nearest lot line____________._.__ <br /> ❑ ----------------- <br /> Number of lines-----------------------------------Length of each line--------_---------------------Width of trent ---____---�-___-- <br /> Type of filter material_________________________Depth of filter material_______.______________ <br /> { ' ------ <br /> Remodeling and/or repairing (describe):_______ '�-�"""-`-'-�' ---1--"-------�-��-•�'�'''�"`�`�� <br /> I ------------------------- <br /> ------------------------------------------------------------------- - <br /> --------------------------------------------------------------------------------- <br /> I hereby cer+ify,+hat I have prepared +his 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 /> �(� Contractor) <br /> � (S�gned)�e.---L�=-- C�--------------------------------- <br /> ---------- ------------------------------- ----------------------------- (Title)- . 5� r�-r�+ �l ----------------------- <br /> t <br /> By: " <br /> } (Plot plans, sh,' ing size of lot, locati s+em in relation to wells, buildings, etc., must be filed wi+h this application). <br /> FOR'DEPARTMENT USE ONLY , <br /> DATE---- ---------------------------j <br /> APPLICATION ACCEPTED BY------ ------------------ -------- - -- <br /> --- <br /> -V <br /> REVIEWED BY----------------------------------- ------------------------------------ <br /> -I e----------------------- <br /> - --------------------------------------------- DATE = _ .�----------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------- ------------------------------------ ----- <br /> ---------------------- DATE----------------------------------------------------....-:... <br /> Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- <br /> -------------------••-----------------•---------------------------------------- <br /> p ------ ----- ---- <br /> ______________________,_________--__________________-- <br /> ------------------------ ---------------- -----------------------------------------------------------------11------------------------------------------------------------------------- <br /> _ _ _______________________________________________________________________________,-_____-____--____._____"-____-________________________-______---______________--_-________-___ <br /> � <br /> -------- ISSUED_--z-=--rx ��-----(Date] FINAL INSPECTION BY:----- 4 _7�P '-1---------- <br /> � PERMIT No.___ _ . <br /> Date----------- ` ` ;' <br /> g <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> ¢ 130 South American Street <br /> Stockton, California ! <br /> ES-9---2M 9-50 W-1639 <br />