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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------149-- --?`-'------- '----4-�------------'5------------ -------- <br /> 6wner's'Name:__ 4J;....IR-----•--'� 1•�J '` ---------•-----------------•-•-----------------••-•----•-...................... Phone--_-._------------- ---•----- <br /> Address. !�'_ -- ►,... ------------- ----.............—..................................................•---------•- <br /> ----- <br /> b <br /> i - • w .� <br /> Contractor's Name_............ ................=..................................................---•---------•--....................... Phone----------- t................ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Coupt-❑ Motel ❑ Other <br /> Number of living units: ❑ Number of bedrooms E] Number of baths ❑ Lot siz --- __ -------------- <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 Hardpan ❑� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -- <br /> r .. � d <br /> Septic Tank: Distance from nearest'well----A9_-__-6istance from foundation-------1L?.......Material..........C.-k t -_.' ....... <br /> No. of compartments__-----_- "____......Capacity.... Size---jO)C.E1_}5._( _..Liquid depth--------__!/--------..V <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 lot line----------------------------.-------_-------•--- <br /> Seepage Pit: Distance.to neared.well.......................Distance from foundation....................Distance to nearest lot line............. <br /> ❑ Number of pits........-_--'._.__Lining material-°`_'"''„�'�"Sii:—Diameter....................•-•Depth------._-------------................................. <br /> z ..l rQDistance to ReldDistance <br /> nearest well...00: Distance <br /> nearest lot lime.. <br /> Numof In _ of line l�� .Width of trench.....? .................. <br /> Type of,fltermDepth . <br /> of fi+ter material_-_-__--/. ._..:... <br /> Remodeling and/or repairin,c� (describe):__--____. ._t0.-__4_-P-_.-_-_ ._-___ > .._____.r_4/__. _- .Q-1!'L•-•------- <br /> s� ��...._. . I <br /> —.. �`t4 ��... >�+' — ?4` l+nt 4�' lstl-t = - ' J Pr� Aa-. r ? 4%-Al <br /> .......... 1Ar---------------•--- <br /> --------wr�-; 1-;,:. Z� ------------------------------------------------------------------------------- <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 la>ys and rules acid/regulations of the San Joaquin Local Health Disfrict. <br /> 44 <br /> ..._.. Owner and/or Contracfo� <br /> (Signed) ----•------ .._. - / ) <br /> 10 <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.:........... ~ ------ <br /> - --•---•-•--- ':_... DATE__..... `.- ►9'�- •- <br /> REVIEWEDBY•. .: :T`-----------------•---•------•---------------•-•-----------•------ DATE................. ......................................... <br /> WiLDINPERMIT ISSt'JED- •-•---••--••-............................----------------•----•-•-------------------------•-- DATE- ----- <br /> Alterations and/or'tecommendations:.:---------•----•--•------------------...............--.............................................................--._...._...---•-----••-.............. <br /> { <br /> --------------------------------•-----•----------_..................................------------------....---•----...__...............-----•---...-_.................----•------------------............................ <br /> -••-•----•------------------------------------ -------------------------- ............--•--••-•-----••----•-•---••-•••.......-•----••----•--......---•--•-•--••--•-•.............------••--•----._....--- - <br /> - ---------------- . .---- -------- ----------•-•- •. - --------- -------------------------------------•-------....... ............. -------------------........................ <br /> PERMIT Ng�_ .: _-- ISSUED------ --- J _.(Date) FINAL INSPECTION BY:. -- ___...'--.------•-_---.----•---------------- <br /> Date. �ff-------------------•--•----------------•- { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 1 <br /> Stockton, California i <br /> ES-9-2M 9-50 W=1639 <br /> J <br />