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,� • APPLICATION FOR SANITATION PERMIT a <br /> 3 (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 /> JOB ADDRESS AND LOCATION � d 5------ - - <br /> Owner's Name......... <br /> �_P;--------- <br /> Address__-.----•---------------�_A -------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name-------------- ---- -- ------- ------------------------------ - <br /> ------------------------------------------------------------ Phone----y-�---�-�--�'-------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> - -- --- � - ...:----- -- -------- <br /> Water Supply: Public system wl-r-ommunity system ❑ Private ❑ -Depth to Water Table Y,-1—ft. <br /> Character of sail +e a rlanA nf x 4!nn+•' [a.,a r--i r; s,, 1 r i c a.. i ----- r-i /71_.. 1 __.__ . i <br /> Character of soil to a depth of-3 feet: Sand 0 Gravel ❑ -Sandy Loam ❑" Clay Loam ❑,_Clay ❑ Adobe 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 from foundation--------------------Material_____________-______________--_-_--_______-____- <br /> ❑ No. of compartments--------------------------Capacity-----------------------Size------------------------ ....Liquid depth r <br /> Cesspool: Distance from nearest well---Ar__0----Distance from foundation-----�_4+_--------Lining s material----�fa_k----- <br /> Size: Diameter------- E-------------------Depth------------ ------------------------------------ <br /> Privy: Distance from-nearest Well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> El <br /> __-_______-____-___________________-_-__❑ Distance to nearest lot line___________-___________________________________ <br /> Seepage Pit: Distance to nearest well---I------------------Distance from foundation--------------------Distance to nearest lot line--__-___-_____-- ` <br /> ❑ Number of pits--------___-_._a----Lining material-----------------------Size: Diameter---------_ p <br /> Disposal Field: Distance from nearest we'll-----------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> Number of lines---------------I------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter`materia------ of filter material______-______________- <br /> Remodeling and/or re airing (descriL;e) - rr±+N L � -'-----�----Lfj-------� I--------------------- <br /> I <br /> " <br /> _-Or = 'd-- r_-Q� ------------------------ <br /> ______________________________________________________________________________________________________________ ________ <br /> {______�______-________.a_______________________________- __-.____ <br /> _____________.___-__--__-----___-___________________________________________-_____________________________ -__-------- --------- _..__--_-_____--_____-__-_______-._---_______-_-_-_--_ � <br /> 1 hereby certify that I have prepared this application and that the work will be Jane in accordance with San Joaquin County r <br /> ordinances, State ws, and rules and regulations of the5an Joaquin-Local Health District. d �1 <br /> I � � <br /> (Signed) ---------- ' -= - (Owner and/or Contractor) <br /> (Title)- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> r <br /> -FOR DEPARTMENT USE ONLY �` �` - <br /> APPLICATION ACCEPTED BY---------- y---t4-------------- --------------------------- DATE----------- <br /> REVIEWED BY --------------------------- DATE---------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------- <br /> ---------- <br /> Alterations and/or recommendations----------------------------------------------------------------- - -- ----•-------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ ------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------­---------- -------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------• ----------- ---------------------------------------------------------------------- <br /> 3vIIT No�___ ___�_______ ISSUED � -s`!--__________(Date) FINAL INSPECTION BY.. ''v__!1___�______. <br /> ----------------------------- <br /> PER, . <br /> Date----------------------- = 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> j Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />