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APPLICATION FOR SANITATION PERMIT z, <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. X49. <br /> JOB ADDRESS AND LOCATION----------- r � ----------- -----------------1 �----- ---------------------------------------------------------------------._--..- ------------------ } <br /> 6 Owner's Name---------------- 5-�`---v-e---------- JF - ---- Phone--------------------- <br /> Address----------------------------------------------- ���1/l t --------------- ---- r <br /> Contractor's Name-------------------------- ��Y ���----------------- ----------------------------------------- Phone_ <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑I Other ❑ <br /> Number of living units- � umber of bedrooms [� Number of baths 6 Lot size____��__�!___/_��____________________________ <br /> I{ , <br /> f Water Supply: Public system J Community system ❑ Private ❑ i <br /> Character of soil to a depth of 3 feet: Sand E❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ <br /> I � <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewof is available within 200 is ncfeet..)_h <br /> i Septic Tank: Distance from nearest well_________________ e from foundation________!�n�Vaterial________________________________________________- <br /> ❑ No. of compartments-----------•--------------Capacity-----------------------Size--------------------------•---.Liquid depth-------------------------- y <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining maferial.------------------------------------- <br /> f–I Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------.---------------- <br /> 171 <br /> _____--- -_-_ <br /> ❑ Distance to nearest lot line______________________________________________ <br /> Seepag 1t: Distance to nearest ell_________________f_Distance frgm foupdation___l0_________-Dis ante to nearest II t line___ <br /> Number of pits________ ___________Linin g material_______ _�`el __ _Size: Diameter_--..______.________.__Depth_;42)___Ss�.♦? <br /> t, Disposal Field: Distance from nearest well _____________Distance from foundation__--M�-�--___Distance to nearest lot line____________ <br /> Number of lines_______________ _ ngth of each line__________ _ _--------Width of french---- _�_____________________ <br /> Type of filter materialC___ epth o filter ecmaterial_________________ <br /> --- <br /> Remodelingand/or repairing ____- I_ ________ -...__.-._?.�_ __ / �-..Lr----- �'._.___ — <br /> / p g -------- # u j <br /> ------------------------------------------------------------------I--------------•--------------------- ----------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------•--------------------------------------------------------------------t------------------------------------------------------------------------------------- <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 regulations of the San Joaquin Local Health""District. <br /> Si ned �_=IS.. X.a_._ ,--_-.-•-_---- -------------------------------------------- ------------------Owner and/or Contractor <br /> By:----------------------- ---------------------------------------- -- ------ - --------------------------------------------------(Title)------ss,------------------------------------------------------- <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 /> APPLICATIONACCEPTED BY --- •--------------------=------------------------------------------------- DATE---------- �----------------------------- <br /> s �W_ <br /> REVIEWEDBY---------------------------- ----------------------------------------------------------------------- DATE----4 �--�'----------------------------------- <br /> BUILDING PERMIT ISSUED--------- •-------------------------------------------------------------------------------------- DATE---------------------------------- <br /> _...---•-------- <br /> Alterations and/or recommendations:-------------------------------------------------------------------.-_.._---------------•------- ------... -------------------------------------- <br /> 5 <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> PERMIT No------------------------- ISSUED----------- ---------------------(Date) FINAL INSPECTION BY:--------------------•-----•------------------------------------- <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 />