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APPLICATION FOR SANITATION PERMIT 6 r <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 LOC TION------ -- — "�'� ------------------------------------------------- <br /> Owner's Name-------------- ---------- ----------- Phone <br /> 11 -------- <br /> t,7 <br /> Address-------------=---------- - ,------------------------------------------------------------------------•-------------------------- =--------- <br /> Contractor's Name---------------i��_ •---.------------- --- Phone--- -- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercialrailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size______________________________________________________________ <br /> Water Supply: Public system ommunity system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.Loam ❑ Clay Loam ❑ Clay ❑ Adobe fft--Hardpan ❑ ( � <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 well_________________Distance from foundation--------------------Material------------------------------------------____-. <br /> No. of compartments--._______;__--___-_____Capacity Size--------------------------------Liquid depth______________11____-_-__ <br /> Cesspool: Distance from nearest well---_-------------Distance from foundation______________-__---Lining material--------------------------�i________. <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----------------------11- ------ <br /> �Qisposal Field: Distance from nearest w 11 —.Distance from foundation___�1_ _- _.Distance to nearest lot in __ II_-_--`--` <br /> Number of lines__ _ fr �l Len th of each line_______ Q-G _ Width of trench_______ _ _ _r� ��__________ <br /> Type of filter material------- <br /> f k2-_- _-Depth of filter material-----_1__7-_________ <br /> Remodeling and/or repairing (describe)----- r ------ ------------•-------------------------------•--------•-- <br /> if___________________________________________________________________________ ---`-"iR1- ---_ ________A__-______--____---__-__________________-____-____-_____---_-____-_-SIT--________ <br /> ________________________________________________________.___-_-________________-.-_-____-_-__.____-_-____---_-----------________.__________--_____________.__-____.__-________--___-__ -______.-_____________________-______-_-_ <br /> i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinI ounty <br /> ordinances, t laws, and rules and regulations of the San Joaquin Local Health District. = <br /> (Signe = '_'��---------------------------------- --------------------------------(Owner and/or Contractor) <br /> By:------------------------------------ ----------------------------------------------------------------------------------=-----(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 <br /> F---- ------ DATE------------- c,3C�-----t�'-----II 4 <br /> APPLICATION ACCEPTED BY--------------------------------------!-------____-- <br /> REVIEWEDBY-----------------------------------1------------------------------------------------------------------------------------------ DATE----------------------------------------------- I�----------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------I—-------- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------__---------------------------------jl---------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------- !----------- <br /> 11 <br /> ----------•--­------------------------- -------------------------------------------------•-------------------------------------------------------------- --------= <br /> ------------------------------------------- ----------- <br /> --------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- <br /> I <br /> PERMIT No._,b__1-__.---_ ISSUED________ ____ __________/,-___(Date) FINAL INSPECTION BY _ <br /> Date--------------- �� � """" _--ji----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 4-50 W-1634 <br />