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' FOR OFFICE USE: <br /> N <br /> a�_-° /i_ -� - ..._-J- _.. APPLICATION FOR SANITATION PERMIT Permit No. ._.�.-. - <br /> J f� (Complete in Duplicatel I <br /> '1 <br /> --------�- - -- ---- -------------- ---------------- --- ry. This Permit Expires 1 Year From Date Issued <br /> Date Issued <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 LOCATI N•_..---� -- � __^ -c cc�C/ a _ <br /> s - .-� ----7 at�?1.w.-_C�f ------- --------------- Phone----------------------•--•-- <br /> Address................. <br /> Owner's eme.-_-_ <br /> !^'1._• f <br /> ---- �. -------�-•---•----------------- T <br /> ---------•• ------`------•-•-------------------- <br /> Contractor's <br /> f-Name---.- --- ------------•-•------------• -------------•--------------------------------------------------------------------- Phone............ <br /> Installation will serve': Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ®— <br /> Numb4 of living units: -------- Number of bedrooms ----- Number of baths -------- Lot size ------------------------------------------................. <br /> Water <br /> ------------------------ <br /> Water Supply: Public system ❑ Community system ❑ Private a—Depth to Water Table+3rft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe []Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ,e New Construction: Yes ®'No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> � A <br /> Septic .arik: Distance from nearest well d-----•Distance from foundation..-Za.......Materiall <br /> f No. of compartments------ ----------------Size�7K•�3`j� f_�_Liquid depth_�� 4 . _- -Ca aci Qd-------_ � <br /> r i p ty/ :.. .. <br /> Disposal Field: Distance from nearest, ell_1�-_-------Distance from foundation------------------Distance to nearest lot line.°0.��:�''"x i <br /> r <br /> a Number of lines-------------- -------------------Length of each linen— __ ��(r~!G !Width of trench.+- . -_--.-.•_- E <br /> Type of filter materia._.__-Pe-____.--_---Depth of filter mater-,,_ 1,____1,r ...........Total length.--- :. -_--- <br /> Seepage Pit: Distance to nearest welly!__--..----__Distance from foundation__!;_'..........Distance to nearest lot line-- <br /> o- Number of pits--_ ---------Lining material'_7t'fk---------Size: Diameter--ke-4---------Depth_..:._ .~`----_..--_-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> El <br /> ---------------.----- -- --_-.---._❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. € . <br /> Privy: Distance from nearest well --------------------__.---_----_,_-_-----------Distance from nearest building------------------------------ <br /> Distance to nearest lot line <br /> Remodeling and/or repairing (describe)----------------------------------------............................ <br /> ----------------------------------------------------------------------------------------------------------------------------- <br /> ------•---•------•------------------------•------•---•--•---•-••----•--...-----•----------------------------------------------------------------------------------•----•------------•---...-_--------•---•----------------- l <br /> -------------------•--------------------••------------------­-------I------------------------------------------------------------------•-----------------------•----Z_-------•----•-----------••---•---------------- l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tyrdMances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed}-------------------------------------------.------ ---- - --------------- ------------------------------•------------- --------- ----.-.(Owner and/or Contractor) <br /> BY: _� ----------------------------------------------------------(Title)---------- ---------- ------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> R DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY-- _:_-- ---- '` - �_ _� DATE-..--------•5 -�1--------- q <br /> ---- ------------- <br /> REVIEWED BY ---•——----••------------------------•-------------------------------------------•--• -------- DATE <br /> BUILDING PERMIT ISSUED------------------------------------- ------------------------------ --------- DATE----------------- -. <br /> Alterations-and/or recom end'ations------ ---- -----17 <br /> - <br /> .- <br /> r t <br /> ----- <br /> ------ -� <br /> - ... �- � - --•----- <br /> a- ` <br /> . -.--••.--------------.-.---•---- ...... <br /> FINAL INSPECTION BY:-.-.- <br /> + -- Date------ �.`- e_-.6`�-------------- <br /> Lf I <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 REVISED 8-99 EM 5-61 ATLAS _A sw ka III <br />