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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 Ordinance No. 549, r <br /> JOB ADDRESS AND LOCATION------1%-•.X-+---6th---at-*-:----------------------------------------------------------------------------------------­------------------------- <br /> Owner's Name------- k'_ ee--------------------------------------------------------------------------------------------- <br /> Phone---2r£i268--------------- <br /> Address--------19--_W +---.6th.--St.01---------------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> Contractor's Name------- ------------------------------------------------------------ Phone---3m39-55- --------------- <br /> Installation <br /> Installation will serve: Residence [Z Apartment House ❑ Commercial ❑ Traiier Court ❑ Motel ❑ Other ❑ <br /> Number of living units: :] Number of bedrooms E2 Number of baths II Lot size------3Q.!x___1Q_O________________________________ <br /> Water Supply: Public system[It Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan 01*_% <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____- u---------________-__. <br /> ® No. of compartments---------2--------------Capacity--------aQQ------Size--- _xr5- id depth 4 ------------------------, <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 /> ❑ Distance to nearest [of line-----------------------------------•------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------_......Distance to nearest lot line_--___-__________ <br /> ® Number of pits-------I-______-___-Lining material-.-Br'_1i.k-----Size. Diameter_....5.2!!-----------Depth__ _-a- . <br /> Disposal Field: Distance from nearest well----- --__-Distance from foundation_____�Q_______Distance to nearest lot line.___.-_-��__---- <br /> _. <br /> ® Number of lines________________ ________ Length- of each line_________1:. ---- ____-Width of french------2 --------------------------- <br /> Depth <br /> _______________----_�__ _ <br /> Type of filter material-------------------- Depth of filter material_________ ________ <br /> Remod li1g and/or repairingdescribe ----------------ST1S ,_a�.lad_ .4?1_-pf---13a'---aeWci ---8�!_'si��-t---•---------•------------------------- <br /> t ----- ------------------------------------------------------------ <br /> -----•----- e� ,�r p <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 /> (Signed) De-It-0 ----------------------------------------------------------------(Owner and/or Contractor) <br /> By:--- - --- -- -- ----------------------------------------------------------(Title)----ownex'T!ice'- ------ <br /> (Plot plans, sh ing ' e oflot, ion of sem in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> Ad <br /> APPLICATION ACCEPTED BY------------------------- DATE-------- <br /> REVIEWEDBY -------- -----•---------------- ------- --------------------------------------------------------------- DATE------1 ' "G``' --------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------- - <br /> Alterationsand/or recommendations*--------- --- --------------------------------------------------------•------------------------------------------•----•------------------------------------ <br /> ------------e�:----------------------=---------------------•---------------------------------------------•-------------------- --------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------- ---------- ---------------------------- <br /> - ----- <br /> - --- <br /> PERMIT No--------to_'_t5 _______ ISSUED------�_L7--�k�_�_C?--------(Date) FINAL INSPECTION BY______________ _ ____ ----- ------ --------- - - ------ <br /> Date----------------- <br /> t / ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-21M 9-50 W=1639 <br />