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r-UK Urt-K t UJt: <br /> T S GS ----- .. ...... <br /> ---------------.- APPLICATION FOR-SARTATION PERMIT Permit No. 9- �_'....... <br /> --------------------- ................... (Complete in Duplicate) <br /> -------- .......­ This Permit Expires 7 Year From Date Issued Date Issued _//116.f,-.-.' <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 Country Ordinance No. 549. <br /> JOB ADDRESS AJ�IND `LOOC,ATION....._.��.�1.. � 1� <br /> Owner's Name---/<<,.__-•`•`amu -------•----------------- -------------------------•-•.......... ........ ....----- -- -------- - ------ Phone.................................... <br /> Address. 2.1 2?-- i.1 ------- -------------------•.._..---•----•-.---•.-• ---------- ...........- ..--------•------------------------.................. <br /> Contractor's Name- - -_.. ---- rx ..... �iLd�r.!'�------------------------- Phone................................... <br /> Installation will serve: Residence ❑ Apar me�eJ' Commercial Trailer Court ❑ Mote Other <br /> ❑ <br /> Number of living units: Number of bedrooms .s_3 Number of baths +57 Lot size /Ao.................. <br /> Water Supply: Public system gj}- Community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ <br /> Previous Application Made: (if yes,date....................) No New Construction: Yes ❑ No U?I�PHA/VA: Yes ❑ No (.rte <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi ank:? D;stance from nearest well.................Distance from foundation_.___--.........--.Material_.........._...--_---_.._._-_.--...._._____... <br /> No. of compartments-- .....................-Size--------------------_--------Liquid depth------ ------------Capacity....................... , <br /> Disposal Field: / Distance from nearest well.................Distance from foundation_�Q_.........._..Distance to nearest lot line_(J:77 <br /> Number of lines.--_L............................Length of eachline_.1uD__.------------ Width of trench....2:4--�'-_-•- r . <br /> Type of filter material.- QG.�.......Depth of filter material_/r."--.---- . <br /> Total length -�Q .•--------------------- <br /> Seepage Pit: Distance to nearest well... <br /> ------- on ram foundation--/A._�._.____ Distance to nearest lot line.._6.��---- � <br /> 9,r- Number of i+s...-1--- --- Depth---._ �._......... <br /> p Lining material... ,_..._ _.,,. Size: Diameter..._c33..4 <br /> Cesspool: Distance from nearest well,................Distance from foundation....................Lining material-..................................... <br /> ❑ Size: Diameter........ .............................De th....................................................Li uid Ca acit <br /> Pq ' P Y••..........................gals. <br /> Privy: Distance from nearest well.................................................Distance from nearest building.]..-___--___-...._...._............... <br /> ❑ Distance +o nearest lot line. -..... ............ <br /> Remodeling and/or repairing (describe)-------------•---. .. ....__.------••--•-•-•--...}___--------`----------- ------------------ -------------_-........*--------------------- <br /> -------- <br /> ----------•------------------ ..................... <br /> ------------------------ ----------------------------- -------------------•------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Cdunty <br /> ordinances, State laws and rules and regulations of the San Joaquin Local Health District. <br /> , <br /> (Signed)_-_- - _-------- ---.--(Owner and/or Contractor) <br /> BY:-------------------------------------- --- ---------------------------.. ........._....--•----------------- - (7ltle)...:` - - <br /> --- ----- --- <br /> (Plot plan, showing size'cf lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ��. <br /> PR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- <br /> - ----------------•-------------- DATE 1 GS°f` <br /> REVIEWEDBY............. ----- ------------------------ ... .. -•---•----.._...... --••-•------ - ...................... DATE.__..... <br /> BUILDING PERMIT ISSUED------------------------- DATE ... <br /> Alterations and/or recommendations:.--------- 9 .._.. ... . ...�� ._.6;- -----•---____-._-• -----•-• :.- <br /> f <br /> _. .} ......... ............._.. ........................... <br /> ....................-............................................. ..---------.._.......-----..-------------------------------------------- - ---------------.....................-....................................... <br /> ---- --••...................•--- . ..._........ ------- ................................................---•--•---------------------- ----•--•--------------_.`..__......................................... i <br /> FINAL INSPECTION BY:. C/. ------------------------ Date......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Mo:elfon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> r.P.c o, <br />