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1 PERMIT APPLICATION FOR SANITATION PE Permit No. ---- <br /> .?Ivrl� (Complete in Duplicate) �/ Z/-t5 <br /> -Y Date Issued .______..-------------- <br /> A)plication 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 /> JOBADDRESS AND LOC. T-1 N----------- F 4 - - `-------------------------------•------------------------------------------------------------ <br /> Owner's'Name------------ ------------------- Phone <br /> Addi <br /> Contractor's Name =� � ..---� R� /'-'u <br /> Installation will serve: Residence Apartment House ❑, Commercial E] Trailer Court El Motel E] OtherOthher <br /> Number of living units: ---!___ Number'of bedrooms ,EPNumber of baths .f_____ Lot size _______c_ 0__NL_V___1i___ ____________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. { <br /> t <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobear pan ❑ <br /> Previous Application Made: Yes [] No New Construction: Yes [j,,la`❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: t <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> eptic nk:� Distance from nearest welL_______________Distance from foundation--------------------Material---- _ _«' "i'"`* _____________-_____- <br /> No. of compartments------------�--------------Size--------------------------------Liquid depth--------------------------Capacity---------------1 <br /> Disposal F' i-: Distance from nearest well-_44_t ._Distance from foundation----- Distance to nearest lot lin__�_________ <br /> Number of lines----------- Length of each line-t�-_2R__ * _ . idth of trench_____________ ___j-_-____________4 <br /> Type of filter material_� Depth of filter material______ - --. Total length_________° <br /> . � I <br /> Seepage Pit: Distance to nearest well__71" ----Distance from .foundation___ _Lz_.._____-Distance to nearest lot line_�_L7______ <br /> _Linin material____ --- Size: Diameter--- • <br /> Number of pits--------�---------- g � Depth-----= -�------ - <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------_-------------Lining material-__________________________________ <br /> ❑ Size: Diameter--------------------------------------Depth-------------------------- -- --------------------Liquid Capacity----------------------------gals <br /> . <br /> Privy: Mstance from nearest weak--------------------------------------r----------Distance from nearest building:----------------------------_____________- <br /> ❑ Distance to nearest lot line---------------------- -------------------------•-------------------------i----- ---------------------------------------•--- -------- <br /> Remodeling and/or repairin& <br /> (describe):--------- '' _--------- <br /> r <br /> ---------------- -- ~ --------------------^��.�. - --------------------- ------------------------------------------------------------ <br /> --------------------------- — f---------------- ',- --------- -----------------_------- }- F ------------------------------------------------------------------- <br /> ti ----------------- --------- = - <br /> I hereby certify that I have prepared this application and that the work wille done'in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)•� � (Owner and/or Contractor) <br /> a $ (Title)_ <br /> ------------------- --------------- -------- ---- - - ---- ------- <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 /> f <br /> APPLICATION ACCEPTED BY------- ----- --- ---- ------------------------------------------------------ DATE----------- "1 ' <br /> REVIEWED BY------------------------------------------------------------- -- DATE-------- �---------- ------------------- <br /> --------------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------=------------ DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------- --------------------------------------------------------------------------------------------------------------------------------------•--.------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------- <br /> -•--------•--------------------------------------------- -- ------ ------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:__-. i� S <br /> ----------------------P"�--'�---------- Date------------------ <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />