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APPLICATION FOR SNAITATION PERMIT Permit No. ..7 <br /> (Complete in Duplicate) <br /> Date issued 4�1�"" <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein de cribed. <br /> This 2pplication is made in com liance with County Ordinance No. 549. <br /> �--✓ <br /> JOB ADDRESS AND LO _ <br /> CATION___ PW--- /�'4 a.%�_t� <br /> Owner's Name-------------- <br /> !✓� ' _ '� �� _ <br /> ------- ------ ----------- - -------- Phone------------------- <br /> Address <br /> _ .. ------------•--------------•------ -----• <br /> Contractor's Name------------------ <br /> _______ _-._.- -__ __ <br /> _ _" <br /> -----•---------------•-------------------------------•------ •--------------------------•-------- Phone__. <br /> Installation will serve: Residence P--A`partment House ❑ Commercial ❑ Trailer Court ❑ Motel p other <br /> p <br /> Number of living units: --l___ Number of bedrooms �_ Number of baths l-" Lot size __ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to ater Tabled ft. a <br /> ----------- <br /> Character of soil to a depth of 3 feet: Sand _ Gravel ❑ Sandy Loam - Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑1 <br /> Previous Application Made: Yes 0 No RT"' Construction: Yes No ❑ <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 w•efi. - --------- <br /> Distance from found{ion_ ______ <br /> (Z No. of compartments-------2--- -----------"Size-- - -- --�(--� Li uid de th-----_ -- <br /> r cl P. Capacity --- - <br /> Disposal Field: Distance from nearest welL.�r�-----Distance from foundation_ --------- Distance to nearest lot line___,"-�__- <br /> Number of lines___"___ -_____----- --___ - Length of each line__19Q �-d ---.-.Width of trench._- �`i4 " <br /> �, , <br /> ' --------------•-- <br /> Type or filter material-" '�_ ---------Depth of filter material---.,1k_-.- <br /> -- ---Total length- --�2�-------Seepage --------------- <br /> Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line__.__________--_ <br /> ❑ Number of pits----------------------Lining material---------------------_ <br /> Size: Diameter----------- ------ ---Depth----------------- -----------•--- <br /> Cesspool: Distance from nearest well__________ _____Distance from foundation._ _ _ <br /> - --"-- ---- Lining m <br /> ❑ Size: Diameter----- - ---- ------------ - -------Depth-------- --------------- ------- - <br /> ---------------Liquid Capacity-------------------- ------gals. <br /> Privy: Distance from nearest well_-.____------------------------------------ Distance from nearest building <br /> ❑ Distance to nearest lot line------ ------------- ----- <br /> Remodelingand/or repairing (describe):--------------_-----------_------------------------------------------------------------------------------------------------------------------------------ <br /> - <br /> ---------------------------------------I----------------------------------------------------------------------------------------------- ------------------I------------------------------------------------------------------ <br /> ----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ------- <br /> ------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------­------------ <br /> ----------------------- <br /> ------------------------------------------------ <br /> I hereby certify that I have prepared-this application and that the work will be done in accordance with Sart Joaquin County <br /> ordinances, State laws, and•rules and regulations of the San Joaquin Local Health District. <br /> (Si ned �2,C.�:_�bA`LC.�� .' + •f�" ��. t_+r-�'�- � � <br /> 9 }/� ---- , ,::� V------------------------------------ - --------------------(Owner and/or Contractor) <br /> By:__-------- ------------------------•----------- Title ___ ____ ___ <br /> (Pl <br /> of plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPART ENT URE ONLY <br /> APPLICATION ACCEPTED BY__-- -"-- --�--- - -- ---- -- - -- - TDA�TE----S�- - <br /> a� •� <br /> REVIEWED BY ------- DATE <br /> BUILDING PERMIT ISSUED-------------------------- <br /> ---- -------------------------- ------------- - ---- <br /> --- -------- <br /> --------- DATE--------------------•------- <br /> -------- <br /> Alterations and/or recommendations:------- <br /> - - - <br /> --------------------------------------- --------------------------------- <br /> FINAL INSPECTION BY:-------------" - _. <br /> ------ --- ------•-------- ----------- Date------------ <br /> SAN <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—at+1 14s446 arw000 12-54 <br />