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z <br /> 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 Ordinance No.�549. <br /> JOB ADDRESS AND LOCATION------ S ' ---0,4 <br /> Owner's Name--------- ------------------------------------------- Phone----------------------------------- <br /> Address--------------­---------- <br /> -------------------------Address-------------------------- ---------- ----- <br /> Contractor's Name_. Phone-------------------- ---- <br /> installation will serve: Residence.❑ Apartment House El Commercial E] Trailer Court ❑ Motel ❑ Other 3 ac <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 E] Gravel E] Sandy Loam El Clay Loam El Clay ❑ Adobe❑ Hardpan [j <br /> E <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--------------4------------------Liquid depth---•---------------------. <br /> ' <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------- __.Lining material------------------------- <br /> Size: Diameter-------------------------- ----•---Depth------------------------- I <br /> Pri Distance from nearest wel ______________________________`_---_------------Distance from <br /> Lnearest building------------------------------------------ <br /> Distance to nearest lot,line--------_------------------------------___:_____ <br /> Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line_--_____..______. <br /> ❑ Number of pits---------------------Lining material-----------------------Size. Diameter-----------------------Depth--------------------------------- <br /> iDisposal Reid: Distance from nearest well------------------ from foundation---------------------Distance to nearest lot line----------------- <br /> ❑ ----_---Length of each line-----------------------------Width of trench------- "' <br /> Number of lines------------•-------------- g ______------ <br /> Type of filter material--------------------_----Depth of filter material_-______-.--_--__--:.__ <br /> . 1 — A ac�1�-� a __l c�. _ -�'�2--- -- 2a�(a- sb� <br /> Remodeling and/or repairing (describee):__ ------------------- y-------•------- r <br /> t.a�f...... ' 3 .. S LL-0`-'"!- "-'-'---° -----,---""" _` ----°`'--- -----`--`r-----'=�---- ----- <br /> �'�` tl o ` �'`' <br /> ---------------------------- ---------- � � -------- <br /> ' - ------- ------------------------------------------------------------------------- <br /> I hereby certify + a+ I have prepared +his applic on and +hat the ork will be done in accordance with San Joaquin-County <br /> ordinances; +ate laws, and rules and regulations of the,San Joaquin Local Health District. <br /> �W <br /> i (Signed] �1 ! r - ---------------------=----------- -----------------------------------------{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 /> s APPLICATION ACCEPTED BY---------------------------- --- -------------------------------------------------- DATE -- <br /> ----------- <br /> REVIEWED BY--------------- ------ DATE--------��-"z ` `�------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------- ---------------------------- <br /> Alterations and/or ommendattons: -------------------------------- ------------------ <br /> -------- -- - ---- ----- - <br /> • <br /> i --•-------- ----------------------•-••--------- ------------------ <br /> -------------•-----------------------•---------------------------------------------------------------- <br /> � - -----------------•-------------------------------------------•---------.---------------------------------------------------------- ------------------------------------------- <br /> -------- -- ---- -------------------- <br /> PERMIT No.______ .r------'-`'-•---- ISSUED-----//--P-------------------------(Date) FINAL INSPECTION -------------- <br /> [-�-- -- --------- <br /> ------ } -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 z <br />