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APPLICATION FOR SANITATION PERMIT o <br /> E (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health strict for a permit to construct and install the work herein described. <br /> This application is made in compliance, with County OrdiW 549. <br /> 3 JOB ADDRESS AND LO ATION------ �---- ----�/��5'�-----� _e-1----0�---- 4 141- <br /> Owner's Name----- / -------- c-------- �?� ------------- Phone--��__--1--� `{- <br /> Address---------------1:5AM --------------- ` -- ------------------------------------------------ <br /> ®, <br /> " Contractor's Name--------------��� _,�.�__ct--- �------�--- J'r1,1��1�?�)�-- -- -� � � �(,�F- Phone--- j <br /> ------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms ;4 Number of baths V Lot size____ --------__ _______________ <br /> Water Supply: Public system / Community system [-IPrivate ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe x <br /> Hardpan? <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 fro foundaj�ion---'t-- ________.,Material_041/�-"R'�_4-_____________,________. <br /> No. of compartments: ______Capacity_ �� le_Sizes-&__-- ---T-l),Liquid depth___��___�f_.___.__ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________________ <br /> ❑ Size: Diameter------0--------------------------------Depth-------------------------------------- ---- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------_----.__-._. <br /> ❑ Distance to nearest lot line________________________________________________ <br /> s .,�f <br /> Seepa a Pit: Distance to nearest well_____`_^"^________Distance om foundation__ -��__-________.Dis a «e to nearest lot lin�e__.�___ ____ <br /> Number of pits_L9/V _______Lining material_ �1 _� �u_Size. Diameter_____ p <br /> De th ,'� %� <br /> .Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ Number of lines---F------------------------------Length of each line-----------------------------.Width of trench-_-----------_------------:--------- <br /> Type,of filter material--------------------------Depth of filter material--_________________.___ <br /> 'Remodeling and/or repairing (describe)- ------ -- ------------------ - ------- --- ----- -- -----____-- <br /> --- <br /> ----------------- - ------------------------------ - -- ---- - --------- - --.- . - - ------ -------/7LU,4#Lfq - ------ ----- <br /> �'--------Ta-----W4-M&-- � - lwell&------- ---------- ' ,� ----- 1 <br /> I hereby certify that I have prepa this application and th a+ +he work will be dp6e in accordance with San Joaquin County <br /> ordinances, 5+a s, and rules an re ulafions o the Sa oa Local Health District. <br /> A R <br /> (Signed]------- -- ----- A [__ � ��' i (Owners a�/orC tractor) <br /> `------ 'BY:---------------------- - --- -= - - --�------ - - ------- ----------- ------------------ ---------- (Ti+le)---- --- - - ---- .:� <br /> (Plot plans, showingsize of lot, location of system in r ation to wells, buildings, etc., must be file ifh This application). <br /> C FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY____ ��_______ <br /> - ------- ------------------------- ---------------------------------------- DATE---- ----------------------------------------- <br /> REVIEWED BY DATE ----------------------- ----------- <br /> % <br /> BUILDING PERMIT ISSUED--------------- ----- --- ------- -- -------------------------------------------------- DATE----------- - ---------------------------- <br /> Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------ <br /> i <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------==--------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------- <br /> ---------------------- <br /> I - - <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=---------------------------- <br /> ---------------------------------------------------------- ---- --- ------------------------------------ <br /> --------------------------------------------------------- -------------------------------- <br /> Y <br /> ---------------------------- <br /> ^��. // t�! / r <br /> PERMIT No.c __ L---_ ISSUED (Date) FINAL INSPECTION BY;,!" �':_.___--- ... --------- <br /> k ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />