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APPLICATION FOR SANITATION PERMIT <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 Ord,nartce No. 549. <br /> JOB ADDRESS AI�I CAT)41 --- ' <br /> ------------------------------------------------------------------ <br /> ---------------- - <br /> Owner's Name_------ ----------- Phone -------�� ----- -- <br /> cc j ! <br /> Address_5 - --t ---- --'--_/ _------ -- ' --------------------------------------------- <br /> -- --- --------------------------------------------------- - -- --- - <br /> Contractor's Name--- ---- - ------ - -- ------------------------------ ---- '=---------------------------------------- Phone <br /> -------------- <br /> .Installation will serve: Residence, I Apartment House ❑ Commercial [] Trailer Court ❑ l Motel ❑ Pther ❑ <br /> Number of living units: [J' Number of bedrooms Number o baths <br /> �] Lot size_ ¢ ------------------------ <br /> Water Supply: Public system ❑ Community system ❑ Private.. ] <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam [] Clay Loam ❑} Clay E] Adobe Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permi++ed if public ewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well_- _Distance fro foundation__ <br /> N�atenal <br /> No. of compartments___________ __ <br /> Capacity Size-- ----------Liquid depth-- -� <br /> -------- ---- <br /> pV <br /> Distance from nearest we11-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> F1Size: Diameter------------------------- ------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well----------------------------------------- <br /> ______Distance from nearest buildin <br /> ❑ Distance to nearest lot line_________ <br /> Seepage Pit: Distance to nearestwell_______________-____Distance from foundation___________________Distance to nearest lot line__-______________ <br /> El Number of pits----F_-- -------------Li ingLmaterial-----------------------Size: Diane er-----------------------Depth------------------------------ <br /> q+ <br /> ..Dispose field: Distance from nearest well_ _- .Distance from foundatio ___ -fK---------Distance to nearestt,191 line_______ <br /> Number of lines_ 4f_____ <br /> ` , Length of each line------- - ------ ----Width of trench__ --------------------------- <br /> Type of filter maieris *t� <br /> _ epth of filter materiaL________� <br /> Remodeling and/or repairing (describe):_____________________________ <br /> ---------------------------------------------- <br /> --------------------------------------------------------------------------------- <br /> ------------------------------------------- <br /> ------------------------------------------------------------------ <br /> s -------------------------------------------- <br /> hat I have prepared +his application and that the work wilE be done in accordance wifh San Joaquin County <br /> I hereby certify t <br /> ordinances,r State laws, 'and rules and :regulations of fhe San Joaquin Local Health District. <br /> (Signed)-'i -- ___--, w-_-- -- ------------(Owner and/or Contractor) <br /> gY� --------------------------------------------------- <br /> (Title)------------------------------------------------------------ <br /> ---- <br /> (Plot plans, sho-wir£ size of lof, location of system in relation to wells, buildings, etc., must'be filed with this application). <br /> S <br /> x FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -- - ------------------ ATE <br /> --------------------------------------- <br /> REVIEWED BY - :-------- __ f <br /> __ _ __________ ___ _____1_____-_______________-______ <br /> BUILDING PERMIT ISSUED----------------- -------------- ------------ / i` <br /> ----------------------- --------------- ----- DATE-------------------------- <br /> r` <br /> Alterations and/or recommendations_______________________-_ <br /> ---------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------- <br /> ------------------------------------- <br /> ---------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------- ---------------------------------------- ----------------:------------------------------------------------------ ---- <br /> I <br /> --------------------------------------------------------------- ------------------------------------------------------------------ <br /> 17 <br /> PERMIT No.-- --9_� -- ISSUED------!.- ------ ---�y------(Date) FINAL INSPECTION BY:---�r�1-- - ------------------------ <br /> Date----------- `_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> E5-9-2M 9-50 W=1639 Stockton, California <br />