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xAS <br /> G" A ICATION FOR SANITATION PERI_' it No. .. ..aJ.�7..... <br /> 7 ( � , 4 (Complete in Duplicate) <br /> Data Issued <br /> Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with C unty Ordinance No. 549. <br /> _ q q/� y� <br /> JOB ADDRESS AND LOCATION--- ----- ----- �t�" - .YL.��-- '--.11...... -:�lc�'" - <br /> ` Owner's Name-- ...... ---..... •G Phone--- - -•------ <br /> Address..._..:.. <br /> Contractor's Name.... •... -------------- .... - - - - -- - <br /> see Installation will serve: Residence 5K"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: =.I_ Number of bedrooms .a2__. Number of baths ._{.... Lot size -----.-----................... <br /> Water Supply: Public system R-1-`&ommunity system ❑ Private ❑ Depth to Water Table Xo- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay/Loam ❑ Clay ❑ Adobe 0--_H�ardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ No <br /> ''• TYPE OF INSTALLATION AND SPECIFICATIONS: o � <br /> (No septic tank or cesspool permitted if public sewer is evade a within 200 feet.) <br /> I <br /> Septic Tank: Distance from nearest well..... Distance from foundation..../if.........Material.e.._C__- g_- <br /> [� No. of compartments_-.-_---.c�...........Size',T.-G._ �... �i.. �Liquid depth...... J�Rr� x <br /> ! <br /> Disposal Field: Distance from nearest well-----�--Distance from foundatio��Q-__r.._...Distance to nearest lot lin g4a._.. \ <br /> Number of lines.............. /I.?; ._.__.. Length of each line......_ _-. ..._.. Width of trench-------*.9471..._............ <br /> Type of filter material.. ----------- of filter material....._11F.-______Total length..._..p9D---------------------7-- <br /> Seepage Pit: Distance to nearest well------- ----...Distance from,foundation......��..---.Distance to nearest lot line�_aa-_-__ (�� <br /> Number of pits--------- material_C_L _-_-_---Size: Diameter.._ 3._...._-_Depth_._ S_....__-___-_.- <br /> f Cesspool: Distance from nearest well-----------__----Distance from foundation. Lining material------------------------------------- <br /> El Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity...........................gals. <br /> Privy: Distance from nearest well___-_---__----------------------------------Distance from nearest building....................................---.. <br /> �. ❑ Distance to nearest lot line ---------------------------------------------=-----------------'---------------------------------------------------- - <br /> Remodeling and/or repairing (describe):--------- --------_--------------------...----------------------------------------------------------•_------------•----....-......---- <br /> -----------I.....................................-----------------_-------------------- ---------------------------------------------------------------------------....--------.---••-----•-•------- <br /> -----------------------------•---------------------._........-----------------------------------------------------------.-------------......--------------------------------------.............-...----- <br /> - ------------------------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State I , and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) -------- S.l_---------.-......_---------------------------------- --------------------. and/or Contractor) <br /> By: - 05_ - ... . ------------------------------ ........ (Title) ( . <br /> t a: y4- - - . <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> E - -- - - - - DATE ----------- <br /> APPLICATION ACCEPTED BY .. _ ..-_ �..-��.f._��.-_. <br /> REVIEWEDBY....................--------------- -------------------- ---------------------------------------------•----------- DATE------------......------.. - _.... - <br /> �. BUILDING PERMIT ISSUED_------------------ ------------- ----------------......................................... DATE------------------------------- -.................. <br /> Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------•- ----------------......----------- I <br /> ------------------- -----... ........................_............................. .....................................-............................................._._............. —_.........--- <br /> L ------------------------------------------------------------------------------------------------------------------•-----------------------------------------------------------------------•------------------- <br /> L ------- ---------- - ------ ------------- ----l- ---------- --------- --- ----- -------------• <br /> FINAL INSPECTION BY:.... - � _ Date. -- <br /> -.. .. - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .. <br /> 130 South American Street 300 Wes} Oak Sfrea} 132 Sycamore Street 814 North "C" STree4 <br /> Stockton, California Lodi, California Manteca, California Tracy. California <br /> b— ES-9-2M 10-52 Revised W-2100 <br />