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LA <br /> APPLICATION 1=0R SANITATION PERMIT Permit No. ...1r1_ G_r <br /> f (Complete in Duplicate) / <br /> 1 Y 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 Ordinance No. 549, <br /> ' d <br /> JOB ADDRESS AND L CATION----- �1�.----- _ .�-_ _ ' <br /> - <br /> • I <br /> Owner's Name------ -- v ------- �. ------- ----- Phone------------------------- <br /> Address------------- - - ----- ------------------- --- =------------------------------- <br /> Contractor's Name--------------- `' N Phone <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Motel [❑ Other ❑ <br /> Number of living units: "'-__ Number of bedrooms __"-" Number of baths ---/-- Lot size --- —----------------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private ff_`5epth to Water Table //0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®r"'Hi—a rdpan ❑ <br /> Previous Application Made: Yes ❑ . No P New Construction: Yes �o ❑ FHA/VA: Yes ❑ No g4-' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> l <br /> Septic Tek: Distance from nearest wel -A010i�'-_Distance from_foundation__2 A------------Material __ _ --------- <br /> .6- I <br /> [� No. of com artments_._.- -Size_ r` __Capacity <br /> P ----- ----t„ -�a�-���------Liquid depth- ��'��S- ------- ----->���------ <br /> Disposal Field: Distance from nearest we11�Q --------Distance from foundation--------------------Distance to nearestlotline__--__-.--------- <br /> - g - '- Width of trench_ _ <br /> Number of lines___-____-�_____ ___ en th of each line___ ___ `( ���_ � <br /> �j ---------------- <br /> Type of filter materialepth of filter material___________ _-Total length__ l�i, ----------------------------- <br /> Seepage <br /> ~_________________________ <br /> See .a e it: Distance to nearest well - _ �' _D•atance from undation______ <br /> P 9 ��Q- ----- ��--___.D- t nce to nearest lot line---- ------------ <br /> IV <br /> Number of pits______(____________Lining material___ -_-.Size: Diameter__- j*T.____.Deptn____._. ______________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation._.-----------------Lining materia)__._____________________.____________ <br /> ❑ Size: Diameter.------------------------ ------Depth----------------------------------------------------Liquid Capacity-----------------------------gals. ' <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________________________ <br /> ❑ Distance to nearest lot line �-yj���---��-"�-��-------------- ------- <br /> -------------------------------------------------- ----!-r--------------------------------------------------------------- <br /> Remodeling and/or repairing describe)------------------?U44-___ ----- ---- - _ s------- . <br /> ---------------------------------------- --- --- --- - ------- <br /> ------=-------- --------------------------------------------------------------------------------------------------- <br /> ------ <br /> --------------------------------------- ------- - <br /> --------------------------------------------------------=--------------- <br /> ------------------------------------------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) __. r Contractor <br /> $Y:----------------------------------------------- - ------- - -- - ------ -----------------------------------`(Title)-------- `.------------ <br /> (Plot plan, showing size of lot, locatio f system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- r+ ------------------------------------ ------------------------------------------- DATE--------- � <br /> REVIEWEDBY------------------------------------------------------------------ ---------------------- ----------------------------------- DATE------------------------------- <br /> BUILDING PERMIT ISSUED--------------•-----------------------------------------------—------------------------------------ DATE <br /> Alterations and/or recommendations:--------=----------------------------------------------------------------------------------------------------------------------------------- ----- ------------ <br /> -------------------•------ 5 r t�1------L)2r4 �-�----- �°icx_` o "=--------- ---------pr t � ----- -------------------------------------------- <br /> ------------- - ' _ .:- -- -------------------------- --------------------------- <br /> �;------- s <br /> -u --b: ---- -------------- <br /> --------------- �7--------Z--,----F-R-cm-----5p_ ^r<< /-------------•-------------- -------------------------------------------------------- <br /> ------ A •----------/ <br /> - - -------------------- <br /> . _ 7----------- <br /> INSPECTION Date------ - _ _. - <br /> p r <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 Revised 1.57 F.P.CO. <br />