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,m APPLICATION FOR SANITATION PERMIT w <br /> _ (Complete in Duplicate) <br /> S <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. 49. <br /> J08ADDRESS AND LOCATION---------------------------------- -r--- ---------------------- ---------- -----------------•------------------------------------------------------ --------- <br /> Owner's Name----------------- ----- =---------- -- - Phone ' <br /> Address ------- ------- ------------------------------------------------------------------ <br /> Contractor's Name------------------------• ---------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑4_0 <br /> Motel L1 Other ❑ Q <br /> Number of living units: Number of bedrooms Lo <br /> umber of baths Lot size___ ,a-_u-. <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 Pg- n—ardpan ❑ <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_�70_______Distance from foundation_-�Q._ MateFi _ <br /> No. of compartments------_"�_--------------Capacity-g�!_Q----------Size__ __..__Liquid depfih____ _.___---____:____. <br /> Cesspo I: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> 0 Size: Diameter--------------------------------------Depth--------------------------------------------------=- <br /> a <br /> Privy: Distance from nearest well________________________________________________Distance from nearest building----------------------------------------- <br /> ❑171 <br /> Distance to nearest lot line-------------------------------------Se,,Ra e Pit: Distance to nearest well___-_-_-______Distance from foundation______.-_ Distance to nearest lot line_-_-__-____ <br /> Number of pits______________________Lining material______._-,-_-_________Size: Diameter.-------------------- <br /> \ __Depth---------- ------------------ <br /> Disposal Field: Distance from nearest well.cS'_�.____.Distance,fror foundation__ -_�- :__Distance_to-nearest-lot'line_''�' .-_-_-_ <br /> Number�of"lines------------------=------ Length of'each line----.1�_t!_____�-r------Width of french----Z-�-�----------------- <br /> 1 a - , <br /> Type of filter material:_________--__----'_____Depth of filter material____ _____________ <br /> t� <br /> Remodeling and/or repairing (describe)-------- ------------------------------------------------------------=--------------------------------------------------------•------------------------- <br /> --------------------------•----------------------------------------------- ------------ --------------------------------------------------------------------------------------------------- -------------------------------- <br /> I hereby c rt'.4y�that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S t laws, and rules and regu tions of the San Joaquin Local Health District. <br /> (Si ned <br /> 9 )------ -------'--=--------------------------- • --•------------------------------------- -- --------------------------------------- - ---------------------{Owner and/or Contractor] <br /> Rj-_7-----F---e---------------------'-;--=---------------------------------------------------------------- (Title))---------------------------------------------------------------- <br /> (Plot pl d s,lthowing 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 --------- ----- <br /> REVIEWED BY. ------- DATE__ __r'^, ., <br /> BUILDING PERMIT ISSUED ------ --- --- ----------------------------- ------------------------- DATE-------------------------- <br /> Alterations and/or recommendations------------------------------------------ ------------------------------------------------------- <br /> ------------------------------------------------•---------------------------------------------------------- ----------------------------------------------------------------------------------------------•-------------------- <br /> --------------------------- ----------------------------------------------------------------------------------------- ----------------------------------- ------------------------------- <br /> ----------------------------------------=------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------- -----•------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------- <br /> ------------------- <br /> G Y _ — <br /> PERMIT No-------- ISSUED---- d_'- - ----5._-l ----(Date) FINAL INSPECTION BY:--------- :-;Of --------------------------------------- <br /> ---- <br /> DateJ -- ------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W 1639 ' <br /> r <br />