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mss) <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete ,in Duplicate) <br /> 1 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,w.ith County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION------------- h ------------------------------------------------ <br /> --------------------------------------- <br /> Owner's Name--- -----------------'' -------------------------------- ---------------------------- Phone <br />• Name <br /> ��- '� <br /> , f `* <br /> _ __�_ __ ____________ _____________________________________ <br /> __ _____ -------- <br /> AL <br /> __ __Address ------=-------- Phone.—Contractor's Name----- <br /> Installation <br /> ` <br /> will serve: Residence ❑ Apartme House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: [V Number of bedrooms [ Number of baths ElLot size__ -��- -`.3 ---------------------- <br /> Water Supply: Public system x Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ElClay ❑ Adobe ' Hardpan ElAs <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-----_--------------Material_____--.________----__________________________- <br /> ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------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 /> Distance <br /> -------"_-------------------------- -- <br /> Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to-nearest well----------------------Distance from fo ndation--------------------bis ace to nearest lot line_-_. ___f <br /> ❑ Number of its___...__ _ ___Linin material_�__.Size: Diameter______ _ _________.Depth___ _ +"--- <br /> E p g <br /> Disposal Field: Distance from nearest well________________Distance from foundation_ Distance to nearest lot lint-__S.___.____ <br /> �'.� - Length of each line----- ��J ..Width of trench r -----------------•- _ <br /> Type of filter material.__=__:-'�____-De tof filter material___-__________________ <br /> p <br /> Remodeling and/or repairing (describe)---------------------= _ �!4, --------------fir----------------------------•------------ <br /> ------- ------------------------------------------ <br /> Z-1-1 <br /> •---------------------------•------------ <br /> �-------' - ------------------------------ <br /> ----------------- <br /> ------------------------•-------------------•------------------------------------------- - <br /> e <br /> ---------------------------- <br /> ---------------------------- ----------------- <br /> ------------------------ o <br /> 1 <br /> i hereby eertify that I have prepared this application and That the vAork will be done in accordance with San Joaquin County <br /> ordinances, S e law a rules d' re lations of t e San quin L al Health District. 1 <br /> (Owner and/or Contractor) <br /> (Signed)----- -- -- - - ---- -- ---- ---- - --- --'-- ------------------------------------------------ <br /> By:__ ___ -- --------------------------------------------------------------(Title}__ '~ ------- <br /> (Plot plans, howing si of ocatiah of system in relation to wells, buildings, etc., musk be filed with this applicatio <br /> =FOR DEPARTMENT USE ONLY # <br /> APPLICATION ACCEPTED BY---------------------------- ---- DATE------ -----------------------------" <br /> REVIEWEDBY------------------------------------------------------- DATE------ A71---------------------------- <br /> BUILDINGPERMIT ISSUED--------------- -------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations----------------------------=----------------------------------------------------------------------------•-•'---------------------------------------------------- <br /> ----------------------------------------------------------------------------------------- --- <br /> --- <br /> ----------------- --------------------------------------------------------- - <br /> -----------------------•---------------------'---------------------------------------------------- ------------------------------------------------------------ <br /> -------------------- ------------------------------------------------------------------------------------------------------------ <br /> PERMIT No.__ _S�------- ISSUED------ -------------(Date) FINAL INSPECTION BY:-------- _ -- <br /> ------------------------------------ <br /> Date---------------------- q- ------------------------- <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT �. R <br /> 130 South American Street I / <br />> Stockton, California �` f <br /> ES-9-2M 9-50 W-1639 �' <br />