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x <br /> APPLICATION FOR SANITATION PERMIT [ O <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons_tr_uct and install the work herein described. <br /> This application is made in compliance with County Ordinance No: 549. <br /> JOB ADDRESS AND LOCA�LON_______-------- <br /> Owner's Name----------------------- ------ --------- - - -------- --- Phone------------------------------------ <br /> Address------------------------- <br /> --------------------- - <br /> Address-------------------•-.r4 ¢ ----------------------------------------•--------- ------------__.-------------------------------•---------------------------------------------------- ------- <br /> Contractor's Name_-.--- ..?­ .'--- -------------------------------------------- -- Phone---------------------------- <br /> ------ <br /> ------------------------------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units; 4 Number.of-bedrooms [ Number of baths Lot size_______/__�!. ___ _f--- <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 y Adobe❑ Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted.if public sewer is available within 200 feet.) L-c <br /> + e f <br /> Septic Tank: Distance from nearest well__�Distance fro foundation___ _ ____ Mater al___ _______________________ { <br /> No. of compartments-----------; .,_______-_Capacity------�U__0---Size............._ Liquid depth__••__________________ 1 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation__________________.Lining material._-----_____----------__-_-_________- �y <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 /> Disposal Field: Distance from nearest well- -Distance frorri•foundatio _.PV '1 _--_Distance to nearest lot line_— <br /> [� Number of lines_______________ _______________-Length of each line------;Q_____ Width of trench_______' �_�_____________ 1 <br /> .-7-------- i <br /> Type of filter material-_/( -L,_ .--_-----Depth of filter material---I-k-______- <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------1� �. <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------.------.---- <br /> - -----------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- <br /> I hereby certify that I have prepared +his 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 /> (Signed)------------ ----------------------------------------------------- - - -------(Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------ <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 <br /> APPLICATION ACCEPTED BY -- DATE---------------------------------- ---------- <br /> REVIEWED BY ------ ------ DATE_ ♦ ry ` .y.. <br /> BUILDING PERMIT ISSUED------._ ---------------------------------------------------------------------- <br /> �- <br /> Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- <br /> ----------------------------------------------------------------------I------------------------•-----------------------------------------------------------------------------------------------•----------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> 3 <br /> } <br /> PERMIT Nol49--&--_�---- ISSUED-.------- --- <br /> Date-------------J-l1aj ��--------------------------- <br /> S_f__--(Date) FINAL INSPECTION BY-------------- 1-_•----------------- - <br /> -------------------- <br /> /� --- -' -------------------------•--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />