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� - 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. 549. <br /> JOB ADDRESS AND LO TIO -------- _ _� off+- r �� � -�--- � y <br /> �f O <br /> Owner's Name-------�'T Phone <br /> Address--------•------------ �. <br /> ! Phone_{ <br /> Contractor's Name__--____- <br /> - --•-- ---- ------------ -------------- ---- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I Number of bedrooms [X Number of baths IY Lot size_/pa---X---/0-Q------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private X <br /> I 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 /> 4 (No septic tank or cesspool permitted if publics ewer is available within 200 feet.) <br /> Septic nk: Distance from nearest well---��------ <br /> Distance from foundation_a(�_____ <br /> Material. <br /> ` No. of compartments_._________._ <br /> Capacity__ Q0--Gii_if_Size-__#x_�X__` gc/Liquid depth-------------------------- <br /> ICesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------__-_____-. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> 'Privy: <br /> -------------------- -----------------------------'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> El Distance to nearest lot line-------------------------------- ------ <br /> 1 Seepage Pit: Distance to nearest well---- --__Distance from foundation--- Distance to nearest lot line_____ <br /> ` ❑ Number of pits----------------------Lining material----------------------- Diameter-----------------------.Depth------------------------- ---- -- <br /> > / / <br /> Disposal eld: Distance from nearest well__GV__ ___.Distance from foundation_A-+�__-------Distance to nearest lot Lige,__��___ <br /> Number of lines---_------/ Length of each line------- 1-b-0r-------_-Width of trench__----2v____!'_f__•------- <br /> V--;/ <br /> Type of filter material __ •_ pth of filter material----------------------- <br /> -Remodeling <br /> __----�________ -_ <br /> ` -Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---•------------------•---•-----------------------------------•---------------••-----------------------------•---------------------------------------------------------------------------------•-----------------------••----- <br /> ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------•---------- <br /> ----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------•------------------- <br /> ' I hereby certify +hat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State s, a d rules nd reg tions o he San Joaquin Local Health District. <br /> (Signed)------- --- ----------- ------------------------------------------------------------------------(Owner and/or Contractor) <br /> ---------------------1 <br /> By:---------------- x ------ -- --------- (Title} <br /> (Plot plans, showing size of lot, location of syste elation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__________ _✓ _- DATE____--C1 z -- <br /> ------------------------------------------------------------------------------ - f <br /> REVIEWED BY------------------------------------------- -------- - <br /> ---------------------------------- ------- ---------------------------- DATE /5�� - --------------------- <br /> BUILDINGPERMIT ISSUED-------------------------- - DATE------------------------------------------------------------- <br /> Alterations and/or recommendations: t °Z l�l -- ` G, <br /> ---•----------------------------------------------•--------------------------------------------------------------------------------------------------------------•---------------------------------------- <br /> --1-----------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------ <br /> ------------------------------­----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------- -------------------- -------------------------------------------------------------------------------------•-- <br /> PERMIT No._.___�Ai!i------- ISSUED------- V_ -_- -- -----------(Date) FINAL INSPECTION BY:----- - --- ----- --- - ------------------ <br /> Date-----------------------91'--- - ------------------------------- <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> I Stockton, California <br /> ES--9-2M 4-50 W-1639 <br />