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APPLICATION FOR SANITATION .PERMIT <br /> {Complete in Duplicate) 4 <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 /> Q y <br /> JOB ADDRESS AND LOCAT N__ -✓-------:/- - ------V1i(1_��---------��� ----------- '- <br /> � Ye - -----------------------------------= --------------- Phone------------------------------------ <br /> Owner's Name ,� =- --- <br /> Address-------------------------------------------------------------------------=------------------------------------------------------------------------------;----------------------------------------------------- <br /> orr <br /> Contractor's Name---------------------- ----- Phone----------_.._.------------_ <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other„n.- -"' <br /> Number of living units: Number of bedrooms A Number of baths � Lot size------ >�--_---_--__-.__.__--_-_-- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand^❑ Gravel ❑ Sandy Loam [Clay Loan.;,'❑ ' Clay ❑ Adobe❑ Hardpan ❑ <br /> ;i <br /> TYpJ OF INSTALLATION-AND <br />..�. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 1 � <br /> Septic ank: 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 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 well_________________Distance from foundation-------------_.-----Distance to nearest lot line___________..-- <br /> Number of lines______________________________ Length of each line------------------------------Width of french--------------- _ ---~ 4 <br /> Type of filter material-------------------------Depth of filter material__-_____---------_--__ <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------- ------------------- ----------------=---------------- <br /> --------------- ° ----- --------- <br /> ---------------�� - --__:::__:___-____- -e- ------A4 , ----- ---------_... <br /> -- --- - <br /> 1 hereby certify that I have prepared this application and that the-workiwill be done in accordance wift San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)..... .,�.- ----' - <br /> {Ownerand/or Confractor <br /> � Title <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 4 <br /> APPLICATION ACCEPTED BY---------- ----------- ---------------------------------------- DATE---- -: <br /> REVIEWEDBY---------------- -------- --_._`- l - -------------.- DATE---------------------------- -------------------- <br /> P-4- <br /> ------------------ <br /> BUILDING PERMIT ISSUED. ;" !P-4- "fir ------ ------- DATE------ r * = = --------------- <br /> Alterations and/or recommendations: ------------=--------------------------- --•---------------------------------------------•-------------------------= -- >c <br /> •----------------------------•--•----------- -------------­--- ------------------ ---------------------- ---------------------•--------• -------------------------- <br /> ---•---- <br /> ------------------------------------------------------------------------------------------------------ ------------------------------------------------------------•------------------- ­_-.--------------- <br /> ----------------------\--------------------------------------------------•----------------------------------------- <br /> ------------------------- <br /> ' <br /> n <br /> PERMIT y___________ ISSUED__--L __ --_ __ _____ -----(Date) FINAL INSPECTION BY:--- _____�-----_ --- <br /> Date----- <br /> __Date - ----C` ----- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 130 South American Street <br /> Stockton, California <br /> i <br /> ES-9-21A 9-50 W-1639 <br />