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• APPLICATION FOR SANITATION PERMIT .� <br /> (Complete in Duplicate) <br /> t <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 Ordinan No. 549. <br /> i <br /> --------------------------------------------------------------------------------- <br /> JOB ADDRESS AND .i TION —� ----------- Y <br /> r Owners Name------- - <br /> ------ Phone------------------------------------ <br /> Address...... 7 '---------------------a--------- - ------------------------------------------------------------------- -------------------- <br /> Contractor's Name---- ' - .+`-------------------------------------------------------`--------------------------- Phone -�7 � <br /> Installation will serve: Residence Apartment House ❑ Commercial'L] Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units:-. Number of bedrooms Number of Baths 'Lot size_____ _________ <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 ❑ Adobe ❑ Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted,if puic sewer is available within 200 feet.) <br /> k <br /> r Septic Tank: Distance from nearest well -------------Distance from foundation-------`------------Material---------- <br /> No, of compartments----- ------------capacity--- -----Size---3.. -�------Liquid depth------�"�---=----------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------.__________-______________.__. . <br /> ❑ Size: Diameter---•'---------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well <br /> -------------------------------------------------Distance from nearest building_________________--_-----____________--_. <br /> [] Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lotline___---_______-_. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-----_----------•---------------- <br /> Disposal Field: Distance from nearest well___ __D.istance from foundation_____ _____.__Distance-to-nearest lot line. <br /> Number of 1Ines_________ a _____ T�__Length of each line----�ti _�0----------Width of trench_ ______ ` ----- <br /> -- <br /> Type of filter material�I- -----Depth of filt r ma <br /> Remodeling and/or repairing (describe):---- i p :_ _-r�� _-9-3--.1.---------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------�f ------------�'--------------------'+" r----------------------------------------------- <br /> t, <br /> r/ , 4 • <br /> . I hereby certify that I have prepared this a plication and that the work` i 6e.done in accordance with San.Joaquin County <br /> ordinances, State laws, a d rules and regulati of the San caquin ca alth District. <br /> (Signed)-------s----- - ---------e4� ---- ------ - �r - ------- -- --- ------------------------ -(Owner <br /> --- or Contractor) . <br /> B ' __--------------------- - -------- --------- ------- ------------------- <br /> f (Plot plans, showing size of ot, loc ton of st m in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------------------ DATE----------------- ----- �------------------------------ <br /> BUILDING <br /> --------- f <br /> ` fr. <br /> REVIEWED BY 4 ----- <br /> f <br /> BUILDING PERMIT ISSUED.--------`--------------------•------- --------------------------------------------------------------- DATE ---------- -J--�--7---�-t�------•--- <br /> ,,`Alterations and/or recommendations:----------------------------------------------------------------------------------- <br /> ----------------------------------•----------------------------------------- - ----------- -------------------------------- <br /> � I.. ►_A+fit 'aa- IvA ri' ` ------�.. ---------------------------------- _ ------ (� ] --------------------------------- <br /> 70? <br /> -------------- <br /> IgAN v A'q <br /> ------------------- -- ------------------�� <br /> Pie f 0?t- ra h h.a 4y,✓ '-------- -------- ----------------------------------------- - --------- ------------ <br /> r, <br /> , 1 <br /> PERMIT No-------_- ------ ISSUED -r��f -----------------(Date) FINAL 1 ECTION ...BY-----=--------w--------------------------------------------- <br /> Date-------•---r--------4�------- --------�---.-------------------- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> 1 <br /> ES-9-2M 9-50 W=1634 <br />