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3 GS <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> { <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND OCATiON- _9--------- <br /> - '...a ------------------------------------------------------------------------------------- <br /> y� <br /> Owner's Name- - ---- s ------------------------------------------------------- Phone------------------------------------ <br /> Address---------------------- _ <br /> Contractor's Name_. ---, -.--- - Phoneme <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms,Z Number of baths Lot size-- r--------------------- <br /> Water Supply: Public system Community system ❑ Private [j <br /> Character of soil to a ae tp h of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe)� Hardpan L1 <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 we11-----------------Distance from foundation--------------------Material_______-___-_.-_-___________._________- <br /> ❑ No. of compartments--------------------------Capacity_ ,-------------------Size--------------------------------Liquid depth-------------------------- <br />.px>• +"Ces"s ool: 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 /> ❑ Distance to nearest lotline___________________________________-.__--______ <br /> Seepage Pit: Distance to nearest well---------------------- from foundation-------------------Distance to nearest lot line-•_______________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth'--__---------------------,---- <br /> Dis osal Field: <br /> ;�-_-Distance..from nearestYwe��"._�'-.D.istance from<foundati��__�!__ __Distance_to�nearest-lotGn�e__�_ ______ <br /> Number of lines------------_____________________-Length of each line__tY___:<_ __�'__.Width of french_--_�_Y'_------------------ <br /> Type <br /> ______-___- --__Type of filter material_l�r-----------------Depth of filter material__-4,9lJ...... <br /> ' r <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --•------------------ <br /> ----------------------------------------------- - ------------------------------ --------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that-1 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 <br /> g )-- '' CJ.•!� - '", "------------------------ mad/or Contractor) <br /> = - ---------------------------------------------------(Title)-- ----------------------- <br /> (Plot plans, s owing 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 - ----------------- <br /> = ------------------------------------------------------------ DATE--------- <br /> REVIEWED <br /> -------REVIEWED BY------------------------------------ --------- ----------------------------------------------------- <br /> -- <br /> - ----------- DATE--------- <br /> BUILDINGPERMIT ISSUED-------------------------------- -------------------------------------------------------=--------------- DATE------------------- <br /> Alterations and/or recommendations----------------------------------------- ----------------------------------------• ---------------------••---------------------------------------------•---- <br /> ------------------------------ --------------------------------------------•------------------------------------------------------------------•------------------------------------------------------------•------- <br /> -----------------------------------•----------•------•-------------------------------------------------------•------------------------------------------------------------------------------------------------------------ <br /> ------•-------------------------------------------------------------------------------------------------- -----------------------------------------------------•------------- ----- ---- -------------------------- <br /> PERMIT No.__''o_,�; ........... 1SSUED-_oz_r-__1_.`f-_ - -------.--(Date) FINAL INSPECTION BY:------------- -- --------- ------- -------------------------- <br /> Date-------------------- <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 />