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FOR OFFIC; USE <br /> APPLICATION FOR SANITATION PERMIT Permit'No. <br /> .................__-• <br /> ..................i(---------------------------------- 1) ,� <br /> -------------------------------------------------- (Complete in Duplicate) <br /> This Permit Expires 1 Year From'Date Issued Date Issued --------- <br />- <br />------------------------------------- - <br /> Application i0ig'r_el3y_­r�6vde to the San Joaquin Local Healfh f District <br /> t r a permit,to construct and install the work herein described. <br /> T <br /> This application is made in compliance with County Ordinance N 0. <br /> JOB ADDRESS AND LO ....... <br /> T N 0._,7 ....... --- -- --- ................................................................................ <br /> Owner's Narne-,..-,;. = - - ------- ----------- Phone.................................... <br /> -------------------------------------- <br /> r <br /> --------------- <br /> --- - ------ --------------------------- <br /> Address... - - --------- <br /> ---------------- AeF-1 -- ---- ----------I--------------- .................. <br /> .......... <br /> Contractor's Name------------- -------------------------- ............. ............ Phone................................... <br /> Installation will serve: Resid6nce 0��partmanf-House E] Commercial 0 Trailer' Jc-burt'E] Motel ID Other 11 <br /> Number of living units: __/__ Number of bedrooms Number of baths Lot'size _3:0.# /diip--------------------------------- <br /> Water Supply; Public system 4KICommunity system [I Private [-] Depth to Water Table­y_V/v ft. <br /> Character of soil to a-deith-of 3 feet:--Sand E] Gravel El Sandy Loam [I Clay Loam" [3 Clay El "Adobe k!ro'Hardpan 0 <br /> p <br /> Previous Application Made: (if yes,date..... No PrNew Construction: Yes Ej', No Zj--1=HA/VA:'Yes ❑ No p— <br /> IT <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:) <br /> (No septic +ank or cesspool permitted if public sewer is available within 200 feet.) <br /> S�ticjank:-' Distance from nearest well-----------------Distance from foundation..........::........Material----------------- ................................ <br /> •------Size--------------------------------Li quid dep�h------------I--------------Ca paci <br /> - tY4......---------------- <br /> P <br /> Disposal Field: Distance from nearest well_-__--1-7�__Distance from foundation./t_:________-Distance to' nearest lot line. ....... <br /> 9?001— Number of lines----------/.../---- Length of each line.------�/,V_�--------------Width of trench..A_ ---Z------------------- <br /> Type of filter material-A -Depth of filter material_,O;V��-------Total length_______X0---I...................... <br /> Seepage Pit: Distance to nearest well------!7!7!7=----Distance fprm fou 1 dation..../10�--------Distance to nearest lot lin .. .......... <br /> Tou <br /> Number of piti�'__/-. I Siie: Diameter-a45"/---------Depfh_,247X_------------- <br /> -----------Lining material- ol. <br /> Cesspool: Distance from <br /> -nearest well-----------------Distance from fobnclation--------------------Lining material---------/--------------------- <br /> ❑ Size: Diamefer-t <br /> -----------------------------------Depth------------------ -----`3--------------Liquid <br /> ------------------- - Capacity-r-�......................gals. <br /> Privy: Distance from.,nearest well-------------------------------------------------Distance from.,.nea'rest building-j......................................... <br /> Distance to nearest lot line._.__.____._-_______._._ `--'__. I <br /> Cl ­------------ --------- ----------------------------------------------------------- <br /> --------------------- <br /> Remodeling and/or rep i ribe):-- -------- - <br /> (S4 --------- .1 - ------------------------------------------------------------------ <br /> --- ------ ----- <br /> ----------------------­­.­:------I---­----­--------- ------------------------------------------------------------------------------- ------------------- ..................­­----------------------- <br /> ----------------------------------------------------------- ......................*--------*----------*----------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------I------------------------------------------------- -----------------------------------------------I-------------­-----I— <br /> s, --------------------------------------- <br /> I hereby certify that I have prepared this and that the work will be done in-.accardance with-Un Joaquin County <br /> ordinances, State laws, and ru. sand regu a ipI7 of the San Joaquin Local Health Dis4rict. <br /> I t, <br /> (Si§hed)........................; _.�--- -- -------- ------------------ --- - --- --------------------------- ------------- w, Contractor) <br /> ------------ --- ---- -------------- <br /> ... Rle)--- <br /> By:.......................................................... --------------- <br /> (Plot plan, showing size of lot, location of system in r Ion to wells, buildings, etc., can be placed on reverse side). <br /> DEPARTMENT USE ONLY <br /> APPLICATION AC,�EPTED,-BY---kl� --,/;.,�l-)----(t'lc <br /> _1 ------------------------------------- DATE----- - T . <br /> BY--------------------------------------------- --------------------- ----------- ---------------------------------------------- DATE------------------- .................................... <br /> BUILDINGPERMIT ISSUED------------------------------------------ ---•-----------•------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:---------------------------------------- -----------------------............._------------------------------------------------------------------------------- <br /> ------------------------------------------------I........................------------------------------------------------------------------------............................ ......................I........-------------- <br /> .......................I------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------I............ <br /> ................­.......I-------------------------------------- ------------ -------------------------------------------------------------I----- -------­------------------------------------------------------------------- <br /> ..............................................................................I---------------- ---------------------------------------------------------------------------------------------I----------------1--------- <br /> ..FINAL <br /> --------- <br /> -.FINAL INSPECTION BY: ------ D t -- ---- -Z_ <br /> ----------------------------------- <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 ioai-Amorieaji Street 300 West Oak Street k.1;4 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-09 2M 5-61 ATLAS <br />