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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) Zf gu ) C f7�Z pUSY Ltrc" �/j zYo <br /> l � 7- o5 <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 LOCATION------- 71-7-1---------! -kms---------4` -k-'----------------------------------------------------------------------------------- <br /> Owner's Name-------=- _ -------- ---------------------------------------------------- -------------------------------------- Phone-----------Q4_12-�--------- <br /> y <br /> Address--------- `a --- \41------ " t 1i-1rn-------------------------------------------------------------------------------------------------- <br /> Contractor's Name---------- ------------------- ------------------ Phone--- --------- <br /> Installation will serve: Residence X Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other El <br /> Number of living units: [Z] Number of bedrooms a Number of baths:-EZ Lot size---------� ............................. <br /> Water Supply: %Public system ® Community system ❑ Private ❑ <br /> Character ofisoil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ V <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I <br /> iSeptic Tank: Distance from nearest well_________________Distance from foundation--------------------Material-------------_______________________________- <br /> No. of compartments--------------------------Caacit __ Size--------------------------------Liquid depth_________________________ <br />( Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____________________________________. <br /> ❑ Size: Diameter-------------------------------------Depth-----------------=-------------------------•-------- <br /> f Privy: Distance from nearest well----------------------------.--------------------Distance from nearest building------------------ ________________________ <br /> ❑ Distance to nearest lot line________________________________________________ <br /> s f , <br /> Seepage Pit: Distance to nearest well______________________Dis. ce from u- a�on____. ---------Distance to nearest lot line___________ <br /> Number of pits-------------/-------Lining m terial____f3k,_4_X____Size,: Diameter______ _ __`-______.Depth____-2_.f__'-__.____________ <br /> Distan m oundation_____/'0__�_____Distance to nearest lot l�e:_----F_-__f_.._ ) <br /> Disposal Field: Distance from nearest well ________ � ---------------- <br /> - <br /> Number of lines_(>-----_------_[________________ Length of each line_______ �__�_' -------- <br /> Type <br /> of trench_ s__2- ______ _____ �I <br /> ® Type of filter material_____? G k_______Depth of filter,material-------�-'5.___.___ <br /> Remodeling and/or repairing (describe)_----____------------ tcr_^_ + ' ----------------------------- <br /> -------------------- -----------------------------------------------------------------------------------------------el-•---------- ---------------------------------------------------------•----•------------------- <br /> -�- ------------------ -- -- -- <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 ru es and'' regulations of the San Joaquin Local Health District. <br /> (Signed) ----- u� - - (Owner and/or Contractor) <br /> .... <br /> t <br /> BY: ------ ------------------------------------------------------------------------(Title)----- z',:- --'------------- <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_________ ___---'' �1______-�"" __--------- --------- ------- -- ----- DATE _ __ . �1k <br /> REVIEWEDBY ---------------- -------------- ------�------ ----- --- -- ------ ------ -------- DATE------- -------------------------- ---------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------- ------------ ------------------ <br /> Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------- ----------------------------------------------- <br /> _________________________________________________________________________________________________ ____________________________________•__.___-------------------------------------------------------------Z__2--------------------------------------------- <br /> - �- -f__-_/---- �—=------------------•------------- <br /> ------------------------------------ <br /> 1 �? " �------------------------------------------- <br /> ---------- <br /> ----------------------- <br /> --------------------------------``---------------------------- ------ ---------------1 r f <br /> �. �"___-____ ISSUED--- �__ _'_�__�______________(Date) FINAL INSPECTION BY:___v-_=__ f:__;!__ <br /> PERMIT No--------------- 1f �i.. ----------------------------- <br /> / r e <br /> Date------------------ <br /> A__ ,f` <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />