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� vLA <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Duplicate) 141a <br />Application is hereby made fp the San Joaquin Local Health District for a permit to construct and ins II the work herein described. <br />This application jis made in compliance with County Ordinance No. 549. <br />ZJOB ADDRESS AND LOCATI N___`____ ________________ ---- _a --------- <br />Owner's Name - -----------I-----_------------------------------------------ Phone_�'__ - <br />Address------- _ `---------'----------------------•----------- ~=------------------------------- <br />Contractor's Name --------------------------------------------------------------- ------------------------------------------------------------------------------ Phone -------------------------- <br />Installation <br />--- ----- =Installation will serve: Residence [Apartment House'❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtheEj <br />r <br />_ _-- <br />Y_ <br />Number of living units: � Number of bedrooms ---Number of baths [ Lot size______ _____________ r �'t <br />----------- --------- <br />Number - - - - - <br />Wafer -Supply: 'Public system ❑ Community system ❑ Private A <br />Character of soihfo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Cla Lam E] Clay ❑ Adob`e E] Hardpan ❑ <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__ Y____ Distance from found ation_.__+9`__A--------- -Material__cl____ ___________ <br />No. of compartments --------- _______-_--.Capacity ---- -A 6--------Size--------------------------------Liquid depth ---- ----------- <br />Cesspool: Distance from nearest well -------------- <br />•----- Distance from foundation-------------------- Lining material ---________________________._________- <br />❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br />Privy: Distance from nearest well -------------------------------------------------- from nearest building______________________ <br />-------------------- <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----------------------- Depth ---------------------------------- <br />,DispField: Distance from nearest.wel(____I !____.Distance from _foundation____ ___!___Distance to nearest.lot line ------ 5 <br />Y IJ T Number of lines__________---- ___JLength of each line -------------- * Width of trench ----___._---�-_6---------------- <br />Type of filter material______Depth of filter material_______L_ <br />Remodeling and/or repairing (describe):- ------------------ =';="`'------------------------- ...------------•----•-_.-------- ----------------------------------- <br />----------------------------------------------------------------------------------------------------------------------------------------•--------.----------------------------- ----------------- ---------------------- <br />--------------------•------- =-------------------•-------=--------------------------------------------------•------------------------------ =--------------------------------------------------------------------------- <br />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 />r '�(Signed) ----n �=------------------- - - --�-�---------=--••----------------i ----------------------------------- r ----- ----- - -----------------(Owner nd/or Contractor <br />Ry:-----------------------------------------------------------------------:--=,------------------------------------------------(Title)-------------------------------------- <br />(Plot pians, showing size of lot, location of system in relation=to wells, buildings, efc., must be filed with this application). <br />FOR DEPARTMENT USE ONLY <br />i <br />APPLICATION ACCEPTED BY___________ _____ _ - 0 Z_ _ �� <br />------ --- DATE -- - l <br />REVIEWED. BY ------------------------------------------------------------------------------------------------------------------------------ DATE <br />I« BUILDING PERMIT ISSUED--------------------------------------------------------------------------------`---------------------- DATE----------------------------------------------- <br />Alterations and/or recommendations----------------------=---------------------------------------------------------------------------- - <br />-------------------------------------------------------------•-------------- —--------------------------------------------------..._.._----------------------- <br />------------------- <br />- ------------------- <br />--------' --------------------------------------------------- <br />-----------------:-------------------------------------------------------------------------------------------------------------------------------- <br />- PERMIT No ----- .�Q%_�_____ ISSUED___fP."_.5-'S:_/--------------- (Date) FINAL INSPECTION BY:____ f <br />1 Date------------------ --V. <br />) <br />i a SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1 130 South American Street <br />Stockton, California <br />ES -9-2M 4-5o W-]639 , <br />