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AP�ATION �lFOR' SANITATION PER Permit No. <br /> ---------••--- Coin I ��. <br /> ------------------------------------ -- { pdfe in,Duplicate) <br /> - � Date .Issued ---- ---------�--� <br /> - <br /> ----------- ----------_--.--- This Permit Expires 1. Year From 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 i li ce with County Ordinance . 549. <br /> 4 , com e, ,1 <br /> JOB ADDRESS AND LOCATION ` -- <br /> — • �' :��� hone-- -- <br /> Owner s Name.._ -- <br /> --------------------­------- <br /> Address. <br /> . p <br /> .--- .--- <br /> Address r ---- --- -- <br /> jam,e� <br /> �� <br /> // p <br /> Contractor's Name�hC,r _ --_..-�_.�:. ,{��� ...-- - : . --- �•--.----- r��t=�'=��� -------------- ----- Phone.---1-... -�-- <br /> Installation will serve: Residence- partment House,[] Commercial E] Trailer Court ❑ Motel ❑ Other . <br /> ., ..�. <br /> -Number of living units: -------- Number of bedrooms __-._-': Number of baths -. of size _�//.. -__2--- ---?_�-------— -------------- <br /> Water Supply: Public system E] - Community system ❑ Private ❑ Depth to Water Table -_&)ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay Adobe ardpan <br /> P ❑ �❑ Y. . . ❑ Y ❑ � Y ❑ ❑ ❑ <br /> Previous Application Made: (if yes,date.--------------- ] No ❑ New Construction: Yes 21"N o ❑ FHA/VA: Yes L] No [:] `} <br /> TYPE-OF INSTALLATION AND SPECIFICATIONS:' <br /> (No septic tank or cesspool permitted if public s wer is available within 200 feet.) ' <br /> Septic Tank: Distance from nearest well-N-l)�Distance from'�oun a!ion-:.-!__a-------Material...- - <br /> Septic <br /> Size.. " Liquid depth- r� Capacity-- <br /> No. of compartments_-- .------ •--- Distance fo -� � <br /> r>~x undati n- 0. /_-_.Distance to nearest lot line:- <br /> Dispose Field: Distance from nearest well-_f�(-- 1�' - <br /> Number of lines________. __. ..__ _ _. .__`Length of.each line---=l ru r,-----.-___._ Width of trench...- - ---------.-_-_.- <br /> Type of. filter materials p �r�---._.__Total length-. r�.�__-_ <br /> �.-_ _L__.•De th of filter material---�- - ---------------•-• •• <br /> Seepage Pit: Distance to nearest well-NONZ._-_.--:Distance from -foundation----- <br /> . ?.-_--__.Dist�n�ce to nearest lot line..r............. <br /> Number of pits......1---------------Lining r6aterial-RO.J --------Size: Diameter-- = -(7----......Depth_---;L <br /> Cesspool: Distante from nearest well------------------'Distance from/foundation........ _- .__ Lining material..................''------------- <br /> ❑ Size: Diameter---------------------------=- ------Depth-----------------•----------- -- ---------------Liquid Capacity gals. <br /> `- Distance from nearest building Privy: Distance from nearest well---------------------------------------•_.....-- 9- -- -------------------------------- <br /> Distance <br /> .- ---.------•-----------•--= -. <br /> • T <br /> ❑ Distance to nearest lot line---------------------..----------------• --- -------- --------------------- ------------------------------------------ --- <br /> I. Remodeling and/or repairing (describe)---- �.. \ -------------------•--------- ---- --•--- <br /> 4 <br /> t <br /> J._ ----------------------------•--- ----- --•-• •-----•---------------- - --------------••---------------------- --- <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 /> ordinance$, State laws, and rules and regulations of the San '_Joaquin Local Health District.. <br /> - � � ��j'-f ' ----------------------------- <br /> (Signed)_ = �w'rrler�and�or Contractor) <br /> -------------------- ---- v <br /> •--•--: --------------------•-• -•-----------------------•---- ----- - -: ---- <br /> -f'--------- --�{= ------------ (TitEe) ..................... ------------------- <br /> By: i r <br /> (Plot plan, showing size of lot, location of system in rela#io t o wefts, buildi s, etc., can be placed an reverse side). <br /> FOR DEPARTMENT USE ONLY pp - <br /> APPLICATION ACCEPTED BY ��f- -------------- DATE---------fl_-_rj-~r 6 <br /> REVIEWED BY -- = DATE <br /> BUILDING PERMIT ISSUED--.. _ ,---- ----- - .... DATE <br /> Alte;a i s and/or recommends 'Qn : -- ---- ---- ' '°,�Cxv ........ <br /> ....- -_-. - ------ ------ --K• --•- --_..----..-..----.--.---...--_....----------------- ---_----.-.-------.--_--_-----.---_-- c•f <br /> .......---------------.---------•--_•__.......--•-T---------------•------ .....--.--_- c-_.. <br /> •�, i <br /> FINAL INSPECTION BY:---------Cy - I �c' �1- Date C = .� ....-• ........ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '1601 E.Haxelton Ave: 300 West Oak Street 124 Sycamore Street . 205 West 4th Street <br /> lif <br /> C <br /> t <br /> M <br /> Lodi,California Manteca, aornia Tracy,California <br /> Stockton,California 1� <br /> ES 9 REViSEC,B-Sr) 3M 3••63 F.p.CC. - �- <br />