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j� <br /> .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. 49. <br /> JOB ADDRESS AND LOCATION---- �_-�------- ------------- -------------------- . -------------------------------------------- <br /> Owner's Name-- __ ------- ------------------------------------- --------------- Phone------------------------------------ <br /> Address <br /> ----------------------------- - <br /> Address--------------------- -- - - - - <br /> ---------------=---------------------------- <br /> = -- -Contractor's Name- f ------------ -- ------ -- ---'------ a---- -------------------------------------------------------- Phone ...---� <br /> Installation will serve: Residence" Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: [V Number of bedrooms Number of baths I Lot size---- I----------------------------[ ` <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 /> Septic Tank: Distance from nearest well___________=__Distance from foundation____19--- ___ Material___-� -------------- <br /> �. <br /> No. of compartments_________________Capacity -------Size_J'41 ______Liquid depth____5'1�_____________ <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 /> El <br /> l <br /> See a' e Pit: Distance to nearest well--.- from f- ndation_ <br /> Number of pits______ __<__e_(___V____ Distance to nearest lot line__ , <br /> - -----•--Size` Diameter------4 --_Dep th-----�� ------- <br /> �� __Lining material_ � __________ <br /> -Disposal Field: Distance from near st'well___________#Distance from foundation--------_____s------Distance to nearest lot lin <br /> ❑ Number of lines--------------------------------------Length of,each line------------------------------Width of trench----------------------------------- <br /> Type <br /> -------------- --------- ------- <br /> Type of filter material------------------------"-Depth of filter material----------------------- <br /> I d <br /> Remodeling and/or repairing (describe):---'-___._-__--___-----I------------------------------------------------------------------- <br /> A <br /> ---------------------- -------------------------- --------------------- <br /> ----------------------------------------------------------------- ?""----- <br /> ----------------- ------------------------------------------------------------- ' <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> Si ned M G ----------------- - ---------[ eP-arrd7or Contractor) <br /> - ---------------- <br /> • Ti}le <br /> ------- --------------- <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 F <br /> APPLICATION ACCEPTED BY------------------------------ <br /> -------------------------------- <br /> `---------- '"- -- -- - DATE---------------- <br /> - <br /> REVIEWED BY------------------------------------------------------ --- ------------------------------------------------------------------- DATE------------ <br /> ---- ------------------------------ <br /> BUILDING PERMIT ISSUED----------------------------------------------------- ------------- ---------- --------------- -- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:--------------------------------------_-.----------------------------------- -------------- ---------------------------------------- <br /> ------------------------ <br /> ------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- ---------------------------------­-- -------------- ------------------------------ ------------------------------------------------------- ----- <br /> KPERMIT No.,S_49_3------- ISSUED--------- FINAL INSPECTION BY:----/ r - <br /> j <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 />