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APPLICATION FOR SANITATION PERMIT iP <br /> (Complete in Duplicate) <br /> j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> his application is made in compliance with County Ordinance No. 549. <br /> C� i <br /> JOB ADDRESS AND LOCATION --------------------- -/-_______ �__ ------------ ------ -- <br /> Owner's Name {� V f •�. --------------- Phone---- <br /> Address--------0---/_7--------- ----------- - ----- - -- ------ ------------ <br /> I <br /> Contractor's Name --------------------------------------------------------------------------------------------------------------- Phone .rte i <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of livingunits: Numbe'vof bedrooms <br /> ❑ � Number of baths � Lot,size-------��_-- ,�--1_�--:------------------- r-` <br /> Water Supply: Public systemACommunity system ❑, Private ❑ W �' <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑• Clay Adobe F1Hardpan E] © y <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tanks Distance fr Bares# well Distance fro oun tion___ } r-t�I anal------- <br /> - <br /> ¢---------- —_ <br /> ❑ No- of mpart encs a ac cze= --� -quid de h .! <br /> I <br /> C sp ol: Distance from Weare t well __-Distance fro f dation- l'-Lining material-_---� . <br /> F Size: Diameter 4-- ---Depth----------—----------------------------- <br /> Priv/y: <br /> --------------------- <br /> Privy: Distance from nearest well------------------3-------------- --------Distance from nearest building <br /> ❑ Distance to nearest lot line--------------------------------------------- <br /> Seepage- Pit: Distance to nearest well---------------------- from found ation-------------------.Distance to nearest lot line-------------- <br /> ❑ <br /> N <br /> i` a umber of pits-----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------__---_-- <br /> i Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line-__-----_-_---_-- <br /> tF❑ Number of-lines„`-------------------------------Length of each line--------------------=-----=Width of trench----------------------------------- <br /> Type of filter material-------------------------Depth of filter material _---__-----__------_--- <br /> Remodeling and/or repairing (describe)------------------------------------------------------- <br /> ------------------------------------------------------•------ ------------------------------------------•----------------------------------------------•---------•------------------------------------------- i <br /> ----- --------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------- -=-----• . <br /> --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------=--------------------------------- <br /> 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, a <br /> k (Signed) ' l --------------------------------------------------------------(Owner and/or Contractor) <br /> BY: --------------- ------- -------------------------------------(Tifle)--------------------------------------------------------------- } <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 /> APPLICATION ACCEPTED BY ----------------- - ------------------------ DATE------------- <br /> REVIEREVIEWED L.- <br /> WED BY------------------------------------- ------------ ------------------------------- -------------------------_----- DATE------------------------------- - ------------------------- ' <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------- ---- <br /> Alterations and/or recommendations----------------------------------------------- ------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- <br /> ------------------------------------------------------------------------------------------=------------------------------------------------------------•------------------------------------------------------------------ <br /> M ------------------------------------------------------- ------ ------------------------------------------------------------- <br /> ERMITNoV_ <br /> ----- ISSUED__-_ �l��j_-�-/-__-_-__(Date) FINAL INSPECTION BY:--------"y1/___V -__ ______________ __ <br /> Date----------- <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> E5-9-2M 9.50 W=1639 <br />