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APPLICATION FOR SANITATION PERMIT <br /> #W3 F <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 /> � --- -------------------- <br /> JOB ADDRESS AND LOCATION__ _--- 1-71r-_-- rd,8,1)(A .� -- ---- <br /> Owner's Name--------- -- �•'Y�'C'-" Phone_ � -- ;.P �� <br /> t�:�Address--------------------------------------------------------------r--- -----------------------�-- ------------------------------ ---------------------------------------------------------- -------------------- <br /> Contractor's Name------------------------_--- Q�°o ---- --------------------------------------------- Phone------------------------------------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: [A Number of bedrooms. `' Number of baths � Lot size___ C?___ __L --------------- <br /> Water Supply: Public system [W Community system ❑ Private ❑ ' 'I','Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam E] Clay ❑ Adobe Lld Hardpan �v <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - 1 <br /> Septic Tank: -Distance from nearest well_________________Distance frfodation____��__ <br /> ------.Material------ ----------------------- ------------. <br /> pacity__ _--Liquid depth------ -------___-- <br /> No. of compartments-------->-------------Ca ___ ?-g_------_Size _ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___---_.---_____.____._--__________. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lotline________________________-__--_____________---_ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line___-___________-. <br /> ❑ Number of pits-----'--------------Lining material-----------------------Size: Diameter------------------------Depth-------------------------------- <br /> Disposal Field: Distance from nearest well-------------------Distance from foundation_____-'Q_- Distance to nearest lot I ne___ .....__ <br /> VNumber of lines....-- '----------- ------- Length 'of each line��-7f--w__------Width of french-------[�------_---------__-- <br /> Type of filter material____ ___Depth of filter material-------- _-- <br /> Remodelingand/or repairing (describe)=-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> _ I <br /> ------------------------------------------------------------------=----------------------------------------------------------------------------+---------------------------------- .. <br /> ---------------------------------------------->---------------- ----------------------------------------------------------------------------------------------- .. <br /> .t <br /> I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws-, d rules and' r ulationsof the San J quip Local Health District. <br /> (Signed)_.-- ---------------------------------------------•--•--•-------------(Owner and/or Contractor) <br /> By:-------------------------------------------------------------------- --------------•------•---------------------------------------(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--------------------------- - - - - -- - DATE-------------------- - <br /> REVIEWED BY------------------------------------------------• -- ------ DATE--------------- <br /> --------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------- ----•------------- <br /> -, w <br /> - 1 ----------------------------------------------------------•-•-------------------- ---------------- <br /> ------------------------- <br /> ------------------------------- -------------------- --------------------- <br /> ---------------------------------- <br /> ---- ----- = '1---------------------------------------------------------------------------------------------------------------------------------- <br /> - <br /> PERMIT No.�--3--- -------- l�`SUED----- ----'-7--9 ---�--��---------(Date) FINAL INSPECTION BY:-Z1/_ <br /> -Y��------------------------------------------------------ <br /> Date---------------- 1-- ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />