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APPLICATION FOR SAWA#'E +1 PEAW ► : .��.1 .. <br /> (Complete in OupbooM —De <br /> Issued ____�_"._.,l.._ <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 compliance with County Ordinance No. 549. <br /> JOB ADDRESS ANDD LOCATION.................. <br /> Owner's Name G. G�s1 4C. „ ...... it. ------------------------ ----------- (Phone- ----Address �� d ------------------------------------------------ ----- - <br /> Contractor's Name..------ --t_--- --7^ ------------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence g?O�,partment House ❑ Commercial ❑ Trailer Court ❑ •!Mote) ❑/ /Other�❑ <br /> Number of living units: ...�__ Number of bedrooms ,A-- Number of baths /-___ Lot size ..Cil.. __ -- .k5_________________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2/Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [20'**New Construction: Yes [D^o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: \ <br /> (No septic tankor cesspool permitted' ublic s er is available within 200 feet �•1 <br /> Septic k: Distance from nearest wel .. ista c, fr fo ation_��, ��tr al --- --- <br /> No. of compartments _______... iz ._ X :.. Liquid fleptlY_.___ __--.--___-_-_Capacity ., <br /> Disposal Field: Distance from nearest wel _ istac�ce from foundation__ ______ istance to nearest lot li <br /> y ,^�rr--- ----- <br /> Number of lines_________ ____ _ ________ Leng#h of each line_.___________ .Q_.f�__.._.Width of trench-_..__..&x. �__..____.______ <br /> Type of filter mater, ._j_ -_-_ epth of filter material_____-$_.__-___Total length------------1��_____________ _ <br /> Seepage Pit: Distance to nearest well---------------------:_Distance from foundation--------------------Distance to nearest lot line-----------_---- <br /> El Number of pits_____________ _______Lining material._._____-_----------Size: Diameter__-__-.__.___.____-____Depth.-------------------------------- <br /> Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material------------------------------------- <br /> Size: <br /> :--_ .___-___________--___-____Size: Diameter---- -------- •---- ------.Depth----- ---- -------------------------------------Liquid Capacity---------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building-_____....-_____________________-__-___-_. <br /> ❑ Distance to nearest lot line--------------------------------------------- ------------------------- <br /> ---------------- <br /> Remodeling and/or repairing (describe):--------- ------------------------------------------•-----------------------------------.............................................................. <br /> • •-------------------------- ------------------------------------ ----------------••------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, State laws, and roles and regulations of the San Joaquin Local Health District. <br /> Si ned ' . . .._A , --------------------------------------------------_---------------------(Owner and/or Contractor) <br /> By-------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.. ------------------------------------------------------­- <br /> -------- ---------- DATE ^ <br /> REVIEWED BY --- ------------ DATE----.a----------••--------------- ------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------------•-------------------------......_. DATE �.......... <br /> Alterations and/or recommendations----------------------- ----------------------------------------------------------------------------•---- V..........=..................--------------- <br /> ---------------------------------------------------------------------------•------- ---------------------------•-•---------------•••-•----•---------------------•---••-------••--•-•---•---•--------------•----•-•--••------- <br /> --------------------------- ----------------------•--------------------- -----------------------------------•------------- ---------------------------------- ------ --------------------------------------------•------ <br /> FINAL INSPECTION BY----------------- 'tt----- ------------- Date----- �- ----- -- <br /> -- ---- --- -------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES--9-2M 10-52 Revised W-2100 <br />