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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. <br /> JOB ADDRESS AND LOCATION--------��-�--�-- d.t'f � G�J '..`-�. <br /> f ', 1 ------------------------------------------------------- Phone------------------------------------ <br /> --- <br /> Name---------�.�`-�:----��/1�_�/"_f--�'-_�_/-�--[�-�_E-:-f�.�r---- <br /> ---------------------------------------- <br /> Address---------- 4 Tf--------- f-_4'__ /' --- <br /> Contractor's Name-------------- '-------------------------------------------------------------- -- ------ <br /> -------------------- Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Otherx CA/Zrs- <br /> Number of living units: ❑ Number of bedrooms 'E] Number of baths ❑ Lot size_-_--•-------------------------------------------------------- <br /> Water Supply: Public system)4�Community system F-1Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E-] Clay Loam E] Clay F] Adobe` Hardpan ❑� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: - <br /> R) <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------------- ----- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____---.----___-----___-___-_---- <br /> ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------- <br /> Priv Distance from nearest welt----_-_ {�`ti w e4 -�_'-___--Distance from nearest building------------------------------------- -- <br /> y: If--------- <br /> Distance to nearest lot line------------- _ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation_--__-_---__----__Distance to nearest lot line----------------- <br /> ElNumber of lines------------------------=----------Length of each line------------------------------Width of trench------------------------------------ <br /> . <br /> g Type of filter material-------------------------Depth of filter <br /> , material--------.---__-_-__-_--r <br /> Remodeling and/or r ------- --r-V-�-�` -----�=:----- ------------ r1 <br /> ----------------- <br /> re airing �describe) <br /> -------------------------•----------------- -------------------------------------- ------------------------•------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 1 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 rulesAnd' regulations of the San Joaquin Local Health District. <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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- DATE 1 Z/ --- ----------------------- <br /> - <br /> REVIEWED BY---------------------------- - --------�----------------------------------------------- DATE----- �' �� ------------------------- <br /> - --------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------ -- :--- DATE---------- ------------------------------ <br /> Alterations and/or r commendations------------ -F ~I J_J_ .S Q r d }� <br /> V <br /> c / <br /> ----------M n1. _F� W I E 1 -1�'' �= T <br /> J -------------------- --------------------------------------------------- <br /> - . -►,�� . <br /> --� -- <br /> ---- ------------------------------------------------------------------------------- ------------------------I------------------ <br /> PERMIT No. ISSUED I'�� 0-------------- (Date) FINAL INSPECTION BY:--------�--U`- ------ -------------------- <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 />