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APPLICATION FOR SA <br /> NITAT[ON PERMIT <br /> Permit No. -a--Z <br /> [Complete in,Duplicate)t • - & s/S3 j <br /> ' 1 �,.- Date Issued ___./ <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 Ordir)ance No.k 549. <br /> JOBADDRESS JD LOCATION._ ----- -- - - ---------------------- ------ -------------------------------------------------------------------------------------------- <br /> Owner's Name --- -- -- ----------- -- ------------------- ------------------ ------------------------- Phone---------- '�_..----------•---- <br /> Address-------- - ----- ! ---[-- ------ -• .. .r�-------------------------•----•-•--------------------------------------------•------------------------ <br /> Contr'actor's Name-- ---- ---------------- ----------------- . ----------------------- -------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: umber of bedrooms ___.____ Number of baths -_ ___- of size __ ____ ______ ----------------- <br /> 'water Supply: Publics stem Community system Q—P-rivate-04qpthfoWater_Table,_______, ,ft. ,,.. <br /> Character of soil to a depth of 3 feet: S;�ONew <br /> Graved ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe /Hardpan ❑ [ <br /> Application Made: Yes No Construction: Yes No ❑ <br /> Previous pp ❑ } , <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) { <br /> Septic Tank: Distance from nearest well----------------IDistance from foundation__.______________.Material ________k----------------------------------------- <br /> ❑ No. of compartments------ ----------------- Size--------------------------------Liquid depth----------- --------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well________________IDlstance'from foundation-----------_-------.Distance to nearest lot line----------------- <br /> El <br /> Number of lines----------------------------------Length of each line-----------------------------Width of trench.-----------------.------:--------- <br /> Type of filter material------------------------_Depth of filter material----------------------- lengthA__________________.______________.__.- ' <br /> Seepage Pit: Distance to nearest well ______________-------Distance.from_foundation-_.___:::----------Distance-to n4arest lot line._____________._. <br /> ❑ Number of pits---_--_af____.- --- ming material-----------------------Size: Diamgier__..____-_ ------------.Dept` ------j-------- __-- <br /> w tt/�` � } <br /> Cessp Distance from rie est II_________ ______ istance fro f4oundation_!-___.______.Lining material__ <br /> Size: Diameter=- ------Dept f Liquid Capacity 9 <br /> Privy: Distance from nearest vrell` r._ _- t._._�---_________------------Distance from nearest building__________.___.______________.__.-_--_._. <br /> ❑ Distance to nearest lot line--------------------------------------------- ----------------------- ----- ------------ ------------------------•---------------------- <br /> -------------------------------•--.- <br /> Remodeling and/or re;ainng (describe)' __ __ - bcL.-�+ -� --` - --- ----- ----- - -- ' <br /> �Npr ------------------ .�..-_7 r r� <br /> r ---------------------------------------- <br /> ----------------------------------------------------- �y----------------------------- •------------ -----V.----- <br /> ------------------------------------------------------- -------------------------------- •----•---------------------------------------------------------------------------------------------------------:------------------- <br /> 1-hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and ruIts and regulations of the San Joaquin Local Health District. <br /> Sined ------------------------------ --------------------------------------------------------- ------------(Owner and/or Contractor) <br /> By:-------- -----------•-•------------------------------------------------------1_--------------------------------------------------(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 /> APPLICATIONACCEPTED_BY-R-------------------------------- `-------- ---------------------•-------------------------- DATE -- <br /> REVIEWED BY---------- J �� DATE <br /> �--------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------- ------------------------------------------------------------------------------- DATE QST <br /> and/or reco me dations: - ---- •.e -- ---------------------- <br /> Alterations <br /> -r = ---------- <br /> -------------- <br /> - <br /> �--------------------------------------------------------------- -- <br /> - � L ,. <br /> -. - `------ -- <br /> ----------------------- <br /> - --- -------- ------------------------------------- ------------- ------------------_-------------------------------- <br /> > <br /> FNAL INSPECTION BY:. to <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 />