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�-S3 <br /> APPLICATION FOR SANITATION PERMIT <br /> l _ (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 /> r <br /> JOB ADDRESS AND LOCATION = nI --/U. _ -�------------------------------- <br /> .L , f� t� phone 7�--------- <br /> Owner's Name-----------------------------=------ ------------------ -W------------------------ <br /> ---- ----------------- ---- - <br /> ------------q---,----------------------------------------- ^� <br /> 3 <br /> Address--------------------- < : .S'o �a� P✓(6� <br /> Contractor's Name--------•----------------- ------------------------------------------------------------------------------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms E1.2-Number'of baths ❑/Lot size___________ ________ <br /> Water Supply: Public system _❑ Community system ❑ Private �' 4V' <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ElClay ❑ Adobe ElHardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well______�O----Distance from foundation_________T_:_____-material_______________________________-__-----_______. <br /> 0` No. of compartments__:____5"-------------Capacity---2'a ze___ Liquid depth----------------------- •. <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 /> ❑ Disfance 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-----------------------Depth-------------------•-----_------- <br /> Oisposal Field: Distance from nearest well-----------------.Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter material-------------------------Depth of filter material______________________ <br /> Remodeling and/or epairing escribe _______ a"_Z _______------------------��t [ c''��_ <br /> I �' - j~ <br /> prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have <br /> :1 ordinances, State I ws, 4nrulos a regulations of the San Joaquin Local Health District. <br /> (Signed)-------------- --------- --- - -- ------- ---------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> -•--------- ----------------------------------- ---------------------------------------------------------------------(Title)---------------------- <br /> (Plot plans, showing size of let, location of system in relation to wells, buildings, etc., must be fled with this application). <br /> FOR DEPARTMENT USE ONLY <br /> j APPLICATION ACCEPTED BY------- __ <br /> r DATE--------- --------------------- <br /> REVIEWEDBY--------------------- ------------ 1J- ------- =------------ ------------------------------------------ DATE--------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------ ----------------------------------------- ---------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> 1 ----------------------------------------------•------------------------------------------------------- <br /> --- - - - --------------------------------------------------------------------------- <br /> ISSUED____.-__ _ �_______{Date) FINAL INSPECTION BY:___________ /-- __ ' <br /> PERMIT No._---- �D �'__-- <br /> 1 _ {Date-- ------�--.��-- - �-- ------------------------------------------------ <br /> SAN <br /> -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street }° <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />