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A <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) r <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 /> rA <br /> JOB ADDRESS AND L CATfON A j-- ------------------------------------------------------------------------------------------------- <br /> �" <br /> Owner's Name---------- Phone <br /> ------------------------------------------ - <br /> Address------------------------ �- -, - .- <br /> 5 <br /> ------------------------------------------------------------------------•---------------------------------------------------------------------- <br /> Contractor's Name- -`_`----------------------------------------------------------------------------------------------- Phone------------------------•--------- <br /> Installation will serve: Residence ❑ arfinenf House ❑ Commercial p Trailer Court ❑ Motel ❑ Other <br /> Number of living units: Number of bedrooms [2�.—W"urnber of baths-,size_____�_S—N_1- --------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ <br /> Character of soil to a depth of-3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9r11qardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ` <br /> h (No septic tank or cesspool permitted if pu6licpwer is available within.200 feet.) ' <br /> Septic Tank: Distance from nearest well___3L)----...Distance from foundation___;T-- Mate __ _ -----_r-_. <br /> h No. of compartments_________Amt___Capacity..��---------Size__, _ _ __ ___, -__Liquid depth_ �`� f___. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________.___________-_________- <br /> f ❑ Size:.Diameter--------------------------------------Depth---------------------------------- <br /> Privy: Distance from nearest well---------------------------------------- from nearest building------------------------------------------ <br /> El Distance to nearest lot line_______________________________________________ <br /> 'Seepage Pit: Distance to nearest well_____________________Distance from foundation-------------------.Distance to nearest lot line---------------_- <br /> p. - g - _- p -- f <br /> Number of its--------------------Linin material_--___-- ----___ Size: Diameter-----------------------De th-- ----------------------____-- <br /> �Dispo�s,al Fwd: Distance from- nearest well________________.Distance from foundation______,.._--.-_____Distance t:o nearest lot line.:.._________:.. <br /> �❑. Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- vv <br /> Type of filter material-------------------------Depth of filter material----------------------- �..i <br /> Ref- odeling and/or repairing (describe)________________ _ __ ----------------------------------- <br /> J <br /> ---_-_ - <br /> ------------- — <br /> --�t <br /> F - - - q l. _______ � _ __ <br /> :C <br /> _ _ _____ _ ______ _ ________________________________________________________________________�..__._.._______ -__ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l <br /> \ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. y <br /> 5i ned ________________(Owner and/or Contractor) p <br /> By:--- ------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plans, howing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> i <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__________ <br /> ------- --- <br /> --------'----------------- ---------------------- -- - --------- DATE----------- ---�--- _ <br /> REVIEWED,BY-------------------------------------------------------------------------------------------------------------------------_--- DATE------------------------------------------------------------ <br /> 'BUILD.ING PERMIT ISSUED-------------------------------------------------------------- ----------------------------------------- DATE <br /> Alterations and/or recommendations:___________________________ ' <br /> r' --=-------------------------------- --------------------------------------------------------- -----------------------------------------------------------•----------------------------------------- <br /> I = ----------------------------------------------------- ------------ ------------------------------------------------------------- <br /> -- ---------------------------------------------------'----------------------------------------------------------------------- --------------------------- <br /> ------ ---------------------•------------------------------ <br /> . ------------------------ -------------- <br /> 7 <br /> PERMIT No._ _+`~ __-- ISSUED_________ __f�'�1S` --------(Date) FINAL INSPECTION BY:______r .. e--- <br /> 4 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 />