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.1S�7 <br /> t <br /> + �� APPLICATION FOR SANITATION PERMIT <br /> "R Y (Complete in Duplicate) <br /> Application is hereby made to the n 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 /> r - e---------------------------------------------------------------------------------------- <br /> JOB ADDRESS AND L]]OCATIOjN�----------�-�-7______s�-------- ��_�"1"1�=----- <br /> Owner's Name----------1J ----k'-----"'' I't d ------------------ Phone y 7 <br /> Address--------------------_-. + -- ----_-----_- ---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name__...........'er"�'�' _O'-------------------------------------------------------------------------------------------------------------- Phone--------------------------- ------ <br /> Installation will serve: ResidenceY Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ! <br /> Number of living units: [] Number of bedrooms [[I Number of baths Q Lot size------- ------- -^____________-__- <br /> Water Supply: Public system ❑ Community system ❑ Private g, <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ - Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑► ,` , <br /> 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.__3'_0-___Distance from foundation_-____- Material____ _�' _�' �'!�_f�-. <br /> 4 No. of compartments--------D----------------Capacity-------OM--__ Size_ !1fs --. -X-t--Liquid depth--------�1-_------------. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------- -_______ <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building---------------------------------------- <br /> ❑ Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line------------------ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h--_------------------------------ <br /> .Disposal Field: Distance from nearest well_-r t?!___Distance from foundation---f1----_______Distance to nearest lot line-------,S+_1_ <br /> Number of lines---------- ------------__------__Length of each line----------�)w __----------:Width of trench------*7-_u`_-_-________-____ <br /> Type of filter materialDepth of filter material_________!_ ____ <br /> Remodeling and/or repairing (describe)___________________ __¢�_-�_____--_ <br /> --------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------- <br /> ---------------------------- <br /> -------------------------------- <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 r <br /> e <br /> g <br /> ulations of the San Joaquin Local Health District. <br /> Sined �..- --------------------------------------------------------~----------------------------------------------------------------(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---------------------- --- " _*4�-�""------------------------------------------ DATE......... 7—-- - <br /> /- <br /> REVIEWEDBY---------------------------------------------------------------- ---- ------------------------------------------------ DATE-------------------- <br /> BUILDING PERMIT ISSUED------------- ------------- ------ - -------------- ATE-- s► - <br /> Al a ations and/or recommendations ____ ,l�j - --- --- -- • - ------ <br /> ---- - - ----- ---- - ---- ---------- --- --- ---- ---- --- --------- <br /> - <br /> � <br /> ----- --- - ------------------------------------------------------- <br /> -------------- <br /> ------------------------------------- - <br /> ISSUED `� Date FINAL INSPECTION BY:---- l7[_ ------`--------------------------------- <br /> PERMIT No._i� ---__ (Date) <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 />