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FOR OFFICE USE: {{ <br /> ----------------------------------------------------- -- 1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. .1... __ _.. � <br /> ------------------------------------------------------------ (Complete in Duplicate) <br /> 'This Permit Expires 3 Year From Date'Issued Date Issued ...................� <br /> I Application is hereby made oto the tarJoaquin Local Health District for a'permit to construct and install the work herein described. <br /> This-.application,is.made.,in complia ce `with County Ordinance No. 549. ' <br /> JOB ADDRESS AND --�------------ c - -- <br /> Owner's Name_____ <br /> -- - �- - - ---i _..�,.�'- -------------------------------------•-------------•- Phone-yG!---4-�---------------- <br /> Address----- <br /> -------Z=--Address----- <br /> Contractor's Name-- <br /> C �r2'*16 1. �-sF------- ---------------• Phone.....................---•---------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ .Trailer ,Court ❑ Motel ❑ Other t4f1aCfVjuG g � <br /> F s t <br /> Number of livina units:.--.--,---- Numb of-9—ed Num6er-of; afh '+ <br /> y�•�• v- � ,a� L'�+=size _ .. <br /> �rat,u'w a Ivor: j jar7u LJ %_7[ VVI LJ Oa[tUy warm L.1 %.1ay warn LLJ %—lay LJ 'hlbuue U narapan Lj <br /> 4f %", t <br /> k Previous Application Made: (If yes,date___________________) No ❑ New'Construction Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 F <br /> M [No septic tank,or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: ,Distance .from nearest well ,5DD #^ Distance from foundStion__.� ____Material_Pf IF: CAS:r-___-OVAP—,_. <br /> IE, "I 'E .��o' of comparf a ts� .-V------------- w_ .._ Z- ------ <br /> -- <br /> Disposal Field: Distance from nearest well__6_0__+_Distance from foundation--L.Q._..f-_._.Distance to nearest lot line______________-- <br /> 4n <br /> _____Len th of each line °- <br /> Number �of lines__..--------�..---------- 9 ���-----------------Width of trench-----��"-------------------- <br /> Type <br /> •----- ---•--•--- <br /> T e of-filter material----- � Depth of filter material___+_L__ .........Total length--- P <br /> Seepage Pit: Distance to nearest!well______________ ------ R 5 zi e'D .'_,Distance to nearest lot Gne____.__._________ <br /> Number of its______________________'LiniR� trriDteraal' from <br /> foundation__ <br /> ❑ N p g ,ameter-----------------------Depth <br /> Ya-+ 1r•�= r� <br /> Cesspool: Distance from I nearest well-----------------Distance from foundation______--_-.__.__-Lining material______-.'.___.________________- <br /> ,, <br /> ❑ -w—' Size. Diameter-------------- -----_Depth------- -------------------------- ---------------Liquid Capacity.---.-----------------------gals. <br /> Priv Disfance�from nearest well _._ � `` <br /> Privy:;. -. Distance*fam'"rieares' ---.-- <br /> Distance.to nearest loft line_____ -" � ±_.. <br /> Remodeling and/or repairing (dascribe)--------------------------- <br /> -------------------------- t----- ................ ------•- ------- ---------•-- -----------------•-- <br /> 11 <br /> ............•-------------------•-----•--WT.--•----•-•--------- -. <br /> _--------•----------------....------.-_ ------------------------•----------------------------------------------------------------------- �R <br /> ----------------------------------------- -----------------------• <br /> _________________________________________________ � <br /> -----------------------------------------•--------------- SV,\ <br />.. <br /> -----_-------------------------------------------------------------------------------------------------------------------------------------------------------------_______------- <br /> _______________________ -------------- , <br /> J <br /> I hereby certify that 16ve prepared this'application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regul ti s of the San Joaquin Local Health District. C <br /> (Signed) ------------------------------------------------ <br /> T�-T> -----------------------------------------(Owner F <br /> and/or Contractor) <br /> B :- -----•------ ••-•--••--. ---- ------------------ -------=----- -------------------­---- Title I. <br /> (Plot plan, showingize o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY------ ---- ---- ----------------- •-------------- ----------------------------- DATE---- .-�° _$_ _ -------------------------- <br /> REVIEWEDBY-------------- ---------------------- -----------•---------------=-------------------------•--------------------------- DATE-----------------...--------•-------- <br /> IBUILDING PERMIT ISSUED--,----•------------------------------------------------------------------- -------------------- DATE--------------------••-----------------------------•_-------- <br /> Alterations and/or recommendations:-_ -_.--_ ..----------------------------------------------- ------------------•----------------------•--------•-------------------------- <br /> i-------- <br /> -------------_--------------------------_--------------------------------- __ ______________K______________ ______________________________ _________________________________________ _________ _____ <br /> FINAL INSPECTION' BY:__'=--..... -_-- _ ---: - "" " Date____-- (J�/, // it <br /> {� -'-r---- -+^'------------(-1------------------------- <br /> // 7 <br /> AN 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 REVI9EO 9.59 F.P.1313.111 6.613 <br />