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U5 <br /> ------ Permit No. <br /> ,� ���jdL--_-- APPLICATION FOR SANITATION PERMIT <br /> ------------------- / <br /> ------------------------ ------------- ------ (Complete in Duplicate) Date Issued ...���1 <br /> _---------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 544X <br /> --------- r-------- :'Z_,e"n- �---••----•---...-.•----•----------------•------------ a <br /> JOB ADDRESS AND LOCATION....... `�:_/�___-- �R'- - -- <br /> Owner's Name------- --y----- -----• ''a ,Y = ------------------ Phone.....------------••---------_----- <br /> Address-----,------•- ----------- - --- �---------------------- ••----------------•- <br /> -------------• --•----------- -----------­----------- <br /> ---------- <br /> Contractor's <br /> -------- ---------- <br /> Contractors Name- ------ - ------------------• ------------------- Phone. -.----------------------•------ <br /> ------- -- <br /> Installation will serve: Residence [5 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: . Number of bedrooms ._.""Number of baths _,l`_ Lot size ------- .©------------- <br /> Water Supply: Public system lg Community system ❑ Private ❑ - Depth to Water Tablejd_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam JR Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date-----------,----..._} No New Construction: Yes R No ❑ FHA/VA: Yes ❑ NOC <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> -� =------ <br /> Septic Tank: Distance from nearest welL...�.�— .Distance from foundation-----��._..---.Material _-.� __�c._-�-.=�r_�. <br /> No. of compartments....._---'�'-------Size_--..',- 3 K_-. __Liquid depth-------- Capacity <br /> Disposal Field: Distance from nearest well..,,f- _-Distance from foundation_-_.. .-...Distance to nearest lot line-------- <br /> 0 Number of lines---------------/------------------Length of each line..-.---------HCl-------Width of trench-----------2-.-- -------__-- <br /> Type of filter material---iZ�­_xL-_Depth of filter material------ --------------Total length__.._------...._;Z4>--------------- <br /> Seepage Pit: Distance to nearest well..-e,,' fes_.-----Distance frpgi foundation___.249�a.......Distance to nearest lot line-----3---!e.. <br /> Number of pits-------- ----------Lining material.--- =, Size: Diameter--.._Z_2----±-----Depth--------2____-j7_1----------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.-------------.----.Lining material--------.-.-----_.--.------..---...... V <br /> ❑ Size: Diameter-------------------------- -----------Depth---------------------------•------------------------Liquid Capacity------------._------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------ ---------------------------------- <br /> Distance <br /> -----._..--- ------.-..--..Distance to nearest lot <br /> � _ line----- ------------- -------------- <br /> ------------ <br /> ------------------------------------------ <br /> rib :-------� � —y �--------Remodelinggand/orrepairing (desc <br /> - -•-----•----------- ------------------------- -------------------------•-- -------••---------------------------•-------- <br /> �r _.cJ� ----------' ---�-g J=..` �+. --•------•--------.-- -------------< -'t".—�.�--Z.-.------g----••------ - -- = -------•F�--. . _.'.•{li^:---"( <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with an quin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ----- ------------------- ----------------------------------------------------------------------(Owner and/or Contractor] <br /> .-. .-------(Title)-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ -----Z - `0' <br /> ---- - .. DATE--------------�- -------------- - <br /> �� <br /> REVIEWED BY ------------------ DATE---------------........----------------------------•------- <br /> -------------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------ --------------- DATE-- <br /> - ----- --- - <br /> -------------- <br /> Alterations and/or recommendations:------- --, rte. `� _ .�. Q1 j`- ------ -- ------------ <br /> c-����...- �v----------------- r <br /> --------------•-----------------------------` ----- <br /> ----------- - <br /> - -------- --- - <br /> �--- _ ---- .rte -- --------------------- � <br /> --- -- --- - <br /> FINAL INSPECTION BY:--- Date �� �'�---•--•-------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES-9 REv19E0 6.69 F.P.rc.2M 6.60 <br />