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APPLICATION FOR SANITATION PERMIT <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 Ord$,' n,, No.A. <br /> go . ........... ---- ------------------------------------------------ <br /> ............ <br /> JOB ADDRESS AND LOCATION----- --- .. .... ------------------- <br /> Owner's Name---- -------- ------------------­-------------------------------------------- Phone---------------------------------- <br /> Address------- <br /> hone------------------------------------ <br /> -9 4 4 - ----_�------ <br /> Address------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------------- <br /> -Contract ' s ----Contractor's Name----D.AA----- -------------------- --- - ---------------------------- Phone <br /> `.Installation will serve: Residence Apartment House L] Commercial 0 Trailer Court [] Motel F] Other E] <br /> F. Number of bedrooms L), Number of baths Ej Lot size_____ --- --------------------------- <br /> Number of living units- -11 An) <br /> Water Supply: Public system F1 Community system I-] Private <br /> Character of soil to a depth of 3 feet: Sand E] Gravel J' Sai-i'dy Loam E] Clay Loam E] Clay [-] AdobeV Hardpan E] <br /> F <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 /> El No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth---_--------- ---------- <br /> Cesspool: Distance from nearest well_____________ _D,stance from foundation-------------------Lining material______________________-_---_____-__-- 1 <br /> ❑ <br /> aterial------------------------------------- <br /> ElSize: Diameter----------------1----------------------Depfh--------------------------------------------------- <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Di0ance to nearest lot line_________________________________________--_--- <br /> f <br /> See e <br /> ine------------------------------------------------ <br /> Seenacie Pit: Distance to nearest well---A�A?_!-Distance from founclafion----- Dista-0ce to nearest [of I;ne----40------I <br /> Number of pits--------/----------Lining maferial--el^---12A S$ize: Diameter----- --------- <br /> Disposal Field: Distance from nearest weII__s,"*__Disfance from foundation------2X!----Distance to nearest lot line_---Ab--- <br /> Number'of lines------- Length'of each line---------7-,S-------------Width of trench-------- 4--------- <br /> P-ix­ gpo 0 <br /> --Deptrof'filter material----_/—---------- <br /> Type of filter material_- K <br /> Remodeling and/or'repairing [describe)------------ ------------------------------------------------- ------------------------------------------------------ -- ----------------------------------------------------I- <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 rules and regulations of the San Joaquin Local Health District. <br /> S, ned I---- --69 %W- ------- ----------- --------------------------------------------(03# � <br /> �or Contractor) <br /> By.--- <br /> 00 - -- ------ ---- - - - - -- ----------------------------------------------------------------(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 <br /> W --------------------------------------------------------------- DATE....... -------------- <br /> ------- <br /> REVIEWEDBY------------------------------------- ------ ---------------------___--------------------------------------------------- DATE:-------------------------------------;-------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------ - --------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------- ------------------------------------------------------I------------------------------------------------------------------------------------- <br /> ---------------------------I------I------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ----------- <br /> ------------------------------------------I------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> PERMIT No.--------------------- ISSUED------------------------------------------(Dame) FINAL INSPECTION BY:---. -------- ------- -------------------- <br /> Date-------------- -- - --- --------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W 163 <br />