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7 y� Permit No. <br /> APPLICATION FOR,x,_ANITATION PERMIT <br /> (Complete in Duplicate) Date Issued - .-- r`- <br /> I,• - <br /> +' is hereby made #o the San Joaquin Local Health District for <br /> o a permit to construct and install the work herein described. <br /> pplica Ian Y <br /> his application is made in compliance with County ordinance <br /> :. t�-- ----- <br /> JOB ADDRESS AND LOCATION---------------- -- ---- Phone----------n ------------------ <br /> ----------------"---------- -.. ._ _ <br /> ------ ------- <br /> - -------------_-------- <br /> ------------ <br /> Owner s Name----'--��•- � ---•-----------•----------•------------ ---- <br /> -- ' ----------------------- <br /> Li <br /> --------• --- <br /> ' ------- Phone------------------------- .i <br /> Address-----------•--------- - . �--------------------------------------------------------- <br /> -----------------•----•-------- <br /> Contractor's Name------------- - <br /> Motel Other ❑ <br /> Apartment. ❑ Commercial ❑ Trailer Court ❑ 4 ❑ <br /> Installation will serve: .Residence ------- <br /> -- --- Lot;size ---•- --�-----�-� -•----------•------ <br /> 3--- Number of baths _- � <br /> Number of living units: -��ommunjty <br /> 1umber of bedrooms „ Private ❑ Depth to Water Table `- ft' <br /> s stem-❑ �`Water 'Supply: Public system Y ❑ y Clay Adobe 2e-Hardpan ❑ `3? <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sc <br /> loam/No ❑e Loam❑ Y ❑ <br /> New Construction. bd \��►1 <br /> Previous Application Made:• Yes ❑ No � { • <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or <br /> cesspool permitted if public sewer is available within 200 feet.)r <br /> P <br /> Distance from nearest well ------Distance from foundation_- Materia_-------- Ca aci ---------- <br /> Septic Tank: ----Size----------------------':' ------Liquid depth-------------- • p ty-----" <br /> _ No. of'.compartments------------- <br /> qsosa Fie Distance from nearest well"__--_-""_-"----Dista of from <br /> each line n'dafiion-----.-------•--_.DVV Distance <br /> ofttrench----------------------------------- <br /> D <br /> 5} lot line <br /> -------------�-- < <br /> Number of lines-------------------- ------------Length <br /> i ----De Depth of filter material----------------=-----Total length------------------------- --•-- ---" <br /> Type.of filter material p ---..Distance to nearest lot line------------------ <br /> .Y <br /> Distance to nearest.well- "_ - Distance from foun�;"tiQn__G�_­ _ ------------------ <br /> J <br /> Seepage it' Number of pits---- J------------Lining material_- lam er__---_ Depth <br /> Lining material <br /> Cesspool: Distance from nearest well------------- Distance from foundation-_-----" Liquid Capacity........__.:-- gals. <br /> Size: Diameter ----- -------=--��Pfih-_-°-.T-----:-:-- :. = t <br /> ❑ •; ^. nearest building=---------------------------------- <br /> Distance from <br /> "`Privy:: Distance from•nearest well-------------- ----------- - }- -------------------------- <br /> ❑ Distance to nearest lot line-- -------------------------------------------- <br /> Distance - ------------ <br /> -------�---------: <br /> iw. <br /> c -- ,-• --�--- - -- --- <br /> Remodeling an or re airing (describe :- - -----•---- <br /> p ..e.+n •--- ------ <br /> --------------- <br /> -------------------------------- _.� �. <br /> --' -------- n- --- --------•-----------••-----•----------------•---'------------------'•---'.-----•------•--------------•--------'-----•^-------•----•---..---------'---•."" <br /> done <br /> 1 hereby certify that I have prepared this application <br /> San JaaauinhLacaI Health eDistr District. <br /> accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of q <br /> ---------- ------------------_---.__-_ (Owner and/or Contractor) <br /> -- ------ <br /> (Signed) . <br /> f - (Title)---�'l�_.-- '--------------------- <br /> 'By:-------------- -- <br /> ------ <br /> (Plot plan, showing siz 'f cation system in relation to wells, buildings, etc., can be placed ori verse side). <br /> FOR DEPARTMENT USE ONLY . .. •- <br /> APPLICATION ACCEPTED BY - <br /> ----------- DATE -------------- --------- <br /> --------------- <br /> DATE .. <br /> REVIEWED BY--------------=--------------- <br /> DATE.------•-- ----."----•----------------- --------•------• <br /> BUILDING PERMIT ISSUED--------------- .- <br /> Alterations and/or recommen awns:---.--_--._--.__" _- - -__-"•-______-"---"__-" <br /> K; ----------•----------------•--• <br /> _."------_."--------- ---'----------------".". <br /> ---------------------------•---_-------•.------•--'•-- ----- '"-------------------- - - - <br /> --------------------------- $ <br /> Date----- --=---- ��"�� F <br /> GENAL INSPECTION, BY:-"_-"".------ -�- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l32 Sycamore Street 814 North "C" Street <br /> 130 South American Street 300 West Oak Street Tracy, California <br /> Stockton, California <br /> Lodi, California Manteca, California <br /> KS-4-2M ; Revised W-2100 <br />