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i6 <br /> d �a 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. <br /> JOB ADDRESS AND LOCATION-_- 1- -- ----------------- `^ -. ---- ---- �1 .w? ------- <br /> Owner's Name_ /r _ `..' - - --- ----------------------------------------------------------------------------------------- Phone------------------------------------ <br /> Address-------1l-1-1--- <br /> Contractor's Name----- ____ __ _-��-�.�..;------ <br /> Phone `-- `� --- <br /> ---------------------------- ------------------------- ------------------------ <br /> Installation will serve: Residence t!f Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ] Number of bedroomsNumber of baths ] Lot size____`- _.,f�____r---- _!______________• ` <br /> Water Supply: Public system ❑ Community system ❑ Private A <br /> I <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe'4 Hardpan U <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: C19 y <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 /> __.,_____________________._____-______________. <br /> ❑ No. of compartments-----------I---------Capacity-----------------------Size------------------ -------Liquid depth------------------------- <br /> Cesspool: Distance from nearest well'__'_________'___Distance from foundation___________________ Lining material______----_--_______________________ <br /> ❑ Size: Diameter--------------------------------------Depth--- I <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----- ___________-_-_____________. , <br /> ❑ Distance to nearest lot line-- ---------------------------------- X ,k <br /> Seepage Pif:44 Distance to nearest well--------_-------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> ❑ Number of pits----------------------Lining'material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> _____ <br /> Disposal Field: Distance from nearest well____ _____Distance from foundation_____ °_____Distance to nearest lot lie___-X__�-- <br /> Number of lines----------------/----------------Length of each line-------- -------------Width of french_____A/__ --------------------- <br /> Type of <br /> ---------------_Typeof filter mat erial_1 ��_ _-Depth of filter material_____- <br /> Aitri_"__ � <br /> Remodeling and/or repairing describe]:__-__P69- =sem!:-.mss , ---- <br /> 6 <br /> . - A�_.- - j----------------- <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 /> fJ <br /> ---------------------------- <br /> Sr ned _ a--�/! <br /> r Contract <br /> BV:------ <br /> (Piot 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 /> C 1 <br /> APPLICATION ACCEPTED BY ° ------------------- DATE <br /> -- ----------- - - -- ------- <br /> REVIEWED BY---------------- = DATE_ <br /> ---------- -------•---- - -------------------- <br /> BUILDING PERMIT ISSUED �,------- --------------------------------------------- -- <br /> ----;----- DATE----- <br /> Alterations <br /> ATE----Alterations and/or reco mendatio=ns_____________ ------ ------- <br /> ------------------------------------------------------- <br /> ----_- <br /> ------------------------------------------------------------------------------------ ----------------w---�-C----. -.----¢-�--,-.-i-�--t--_ <br /> -------------------------- <br /> -------------------------------------------------------------­---------- .........------------------------------------------------------------------------------------------------------------------------------- <br /> ---- <br /> --------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------•-------------------------------- <br /> PERMIT No._�U_I_____________ ISSUED_____�I ___"_____________(Date) FINAL INSPECTION BY:___._______(4!/__V M- <br /> -------------------------------------- <br /> Date----------- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />