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FOR OFFICE USE: <br /> _5 <br /> - .------ APPLICATION FOR SANITATION PERMIT Permit No, ................ <br /> r � <br /> , <br /> f" / Compltbiiri Duplicate} j � , <br /> ------------------------------------- ------------------- <br /> ----------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ' t DS oiw— Z2— <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 complia ce with County Ordinance No. 549. <br /> � u p ` ' <br /> JOB ADDRESS AND LOCATION ;;;#- ...... <br /> _-- 1C�T -- -------------CO�.I. +----- J ��;V-P-.---- <br /> �MI-I-k ...5AN-GT�} �����-r-------------------------------------=----------------•-----Phone........... ----------------........ <br /> Address__N J_l QAK _ = _._=5 = .:.` ------ ---- -�-••-•-- '� '--------_---- <br /> ��� r i rti t: E <br /> Contractor's N me._ Q I �M 1 N -_ %�f__2! M, -------- ........... Phone------•---------------------------- <br /> 1 <br /> Installation will serve: Residence [[Apartment House ❑ Commercial [] Trail r Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___I____ Number of bedrooms Number o athsLat size ..... �_A.CJ�� ---___________________ <br /> Water Supply: Public system ElCommunity,system-[-I Private' "Depth`to'Water"Table 6--ft, <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 2 -Sandy Loam ❑ Clay Loam Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ NN•o,❑ FHA/VA: Yes E] No [I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> 7,k: <br /> ptic tank or cesspool permitted if public sewer is available within 200 feet.) + <br /> Septic Distance from nearest well___ �1_____Distan a fro foundation___!........ .:....Materia)._R- �1wT -___. <br /> r• <br /> No. of compartments _ Size__ __________________________Li uid`de - <br /> p q P Capacity----I C �E <br /> Disposal field: Distance from nearest well.--S- .._Distance from foundation.}_.._r_4�......Distance to nearest lot <br /> Number of lines---------___ --C_________Length of each line____ "# � e- .Width of trench------=Y_-t�__�_____--___ <br /> Type of filter material---P_______K----Depth of filter material____.1_9_______.____Total length______________s_________________________-- Q <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation±.-___________.___.Distance to nearest lot line___________-____ <br /> ❑ Number of pits______________________Lining material-----------------------Size: Diameter.-------- __...._______Depth__.._!_._______________________._ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation ,-------------------Lining material------._ _'_y_ ____-____----------- <br /> El Size: Diameter------------- --------.De th------------------------_ - t_ -------------Liquid Ca aci I P'°I_- - - gals. <br /> Privy: Distance from nearest well_..________________________________________Distance from neare1'buildin 1- ________________.___--------r <br /> y Distance to nearest lot line ---------------- <br /> -------------------1= ---------- --------.------------------------------------ <br /> = I <br /> Remodeling and/or repairing (describe)_--------------------- `, _ __--_._-_-_t <br /> -------•--------------------------------- <br /> 1fI <br /> ---•-•------•-•--------------•------•------•------ --------- ---•---------- -•-------------------------------------------------- ---------------------------------------------------- <br /> -----------------------------------------•------------------------------------------------------------•------------------------------------- --••---------------------------------'`---------`---------------------------- <br /> ------------------------ ------------------------------------------------------------------ <br /> hereby certify that I have prepared this application and-that the work will be done in accordance with SanrlJoaquin County <br /> ordinances, State laws, and ruleland 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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ` � �- - ----------------------- -------- DATE----- 4- -1- ---------------------- <br /> REVIEWEDBY------------------------- ---------•---------------------------------__----------- - ------------------------------------- DATE-----------•--------------------------------•-------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------•----------------------------------------------------- DATE---------------------------------------------................ <br /> Alterations and/or recommendations:-----------P--------------------------------------•-------•---------•-----------------------------••----••-------•---------•-----•-------•-••----------------- <br /> _________________________ __.___-. ....... _______._________________-_______-_ <br /> ------------------------------------------------_----------------------------------_----­------------------- ------------------------------------------------------------------------------------------------------ ------- <br /> FINAL INSPECTION BY:.. ----- Date------ - -------------- <br /> ------------ . $ Q �f3 <br /> SAN JOAQUI 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 /> EB-9 REV1RED B-59 F.P,DO.7M 6-6a <br />