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r~ �� APPLICATION FOR SANITATION, PERMIT <br /> } I (Complete in Duplicate) <br /> Application is hereby made"fo 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 /> II / 3-7---------'��---�GF�.N r��r/�------'� ----(-'-�-------------------- --. <br /> JOB ADDRESS AND CA,TI/ON--------------- -------- ----- - ----- <br /> Owner's Name IV/ fi -�. - ---- Phone--- -- <br /> Address------------------ �, -ff �G I11� - <br /> E = --------- <br /> Contractor's Name I 6ZtJ-hv�►/ = ,--------------------------------------------------------------------------- -- Phone <br /> Installation will serve: Residence [Apartment House ❑� Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: umber of bedrooms [Number of baths El, Lot size__.____-_ b__ C._ --------------------------- <br /> Water Supply: Public system [�Clommunity system ❑ Private ❑ <br /> a <br /> Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E� Clay ❑ Adobe e. Hardpan ❑l <br /> II V <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> Septic (ank: Dktance'sspooi permitted if*public sewer is available within 200 feet.) <br /> No septic tank or ce <br /> I from nearest well_________________Distance from foundation----� ' ___ __ Material--------__!. ' <br /> Impartments----------3-----------Capacity---Fas??'�-C Size--------------------------------Liquid depth------`?tl------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------------ <br /> ❑ Size: Diameter------------------ ----• ---------- Depth-------------------------------- --- ------------ , <br /> II <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distances to nearest lot line---------------_-------------------------------- <br /> p g t <br /> ' See a e Pit: Distances to nearest well______________________Distance from foundation_______-___---____.Distance to nearest lot line---------------- " <br /> ❑ Number"of pits----------------------Lining material-----------------------SizerDiameter-----------------------Depth-------------------_------------- <br /> ,Disposal Field: Distance from nearest well------------------Distance from foundation--- __y----_-____Distance to nearest.Iodine--__-_--_-____.-- <br /> Number�of lines---------- Len�th'bf each-line_-_---- �____-- ------Width of trench---ti-- ----------------- N <br /> Type of!`filter material__�a�__�-_-�ath of filter material_--.-_--_� --_ � f� '-►�- �`-'�- ` <br /> . <br /> describe ------------ --- ------- ----C`-'-----� --- ` ----------- <br /> Remodeling and/or repairing (describe): <br /> --------------------------�/ ;-'-'-- ---A--------------------------------------------------•--------------------------- ------------------------------------------------------------------------`--'----- <br /> --------------------------------------------------------------------------------------------•--------------------------------------------------------------------------- <br /> I hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regula+ions of the San Joaquin Local Health District. ' <br /> I� <br /> (Signed)-- ------------------------------------- (Owner and/or Contractor <br /> $Y- I� (Title) <br /> Plot laps, showing sae of l ------- ---- ----------------------------I )---------------------------------------------------------------- <br /> ( p g [of, location of system in�relation to wells, buildings, etc., must be filed with this application]. <br /> �f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED DATE ?- ------------------- <br /> REVIEWED BY--------•--------- _ BY----- ----- --'-- ----- -- ,-------------------------- <br /> l --- ------- DATE-------------�-`------------ <br /> --T--------------------------------------------------------- - ------- <br /> BUILDINGPERMIT ISSUE ------- ---------------------------------------------------------------------------------------------- DATE----------- y-----------`r--------------- -------•----- <br /> y Alterations and/or recommendations--------------------------------------------------------== - <br /> --------- ----------------------------- ----------------------- -- - <br /> --------------••------------------------------='----•--•------------------------------------------------------------------------------------------------------------------------------------------ <br /> -----------------------------------------------------------------------•--,--------------------------------"---------....------=-----------------------------------------••------------------------------------------ <br /> II <br /> --------------------------------- 'I -----------------------------------------------------------------------------------------------------------------------%-� - ----------------__-- <br /> II L& <br /> AA// <br /> J <br /> PERMIT No.--"/3 <br /> - -------------- ISSUED----�� L7-�s'Q -------=-(Date) FINAL INSPECTION BY:---------�1�_--------------------------------------- <br /> 11 Date-------------------- 1 r u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> II 130 South American Street ' <br /> If <br /> I` Stockton, California <br /> ES-9-2M 9-50 W-1639 y <br />