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APPLICATION FOR SA TATION PERMIT Permit No. ` . <br /> I........ <br /> 12 (Complete in Duplicate) I jj-� <br /> -Date Issued /1"�-/__._..___: <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 CoLpfy Ordin e//No. 549. <br /> JOB ADDRESS AND LOCATION •----•.-6(--- -------- ---•--ts moi_ ---mij*........................................... <br /> - <br /> Owner's Name- - Phone <br /> Address- --------- •------------- - -•-•-- ----- -• --- <br /> Contractor's Name----------- _1------- --------------------------------------------I- •------- Phone' <br /> Installation will serve: Residence/ Apartment House F1 Commercial E] Trailer Court 171 Motel ❑ Other EJ <br /> Number of living units: _-I--__ umber of bedrooms _1____ Number of baths _1-__- Lot size -----4PPXJ-0-0----------------_____- <br /> Water Supply: Public system ❑ Community systemA Private E] Depth to Water Table ; ftt <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay C Adobe[] Hardpan ❑ <br /> Previous Application Made: Y s o New Construction: Yes No ❑ <br /> TYPE OF 1NSTALLATI E IFIC T NS: <br /> (No septic tank or cesspool permitted F public sewer 'yyrjav�i) I off 200 feet.) <br /> ��E.JC. n <br /> Septic Tank: Distance from nearest welhle '-- Vistance froW foun ation__ --------M ` Cciy- <br /> ____Liquid depth____ ____________ apat _-_-_No. of compartment --------- ---------------Size_ _ <br /> Disp I Field: Distance from nearest well �.__Distance from foundation !.� :Distance to nearest lot line <br /> Number of lines--------1.- ._ ength of each line_....? ` fir` Width of trench ot.4- -- <br /> . <br /> of filter material..:_ __._ _ epth of filter material.._____� ----------Total length"..--.' <br /> ------------------------ <br /> Seepage <br /> AL- <br /> Type + _________ _________ <br /> Seepage Pit: Distance to nearest'well_.--------------------Distance from foundation-_-_______--____-.Distance to nearest lot line_--------------- <br /> F-1 Number of pits-------- _.----Lining material--_ ---------------Size: Diameter_______ _____-.-._.--.Depth....__.._ _____-------------- <br /> CesspooL Distance from nearest well -•__-_Distance from foundation_________ _____---Lining material--------------------- .......... <br /> ❑ Size: Diameter---- ------Depth---- - -------_---------------------------Liquid Capacity ------_ - --•-----gals. <br /> Privy: Distance from nearest well________ _________ _____--------------------Distance from nearest building--__- -- ._-_-_-_ .•..._.. ,.__._._.' <br /> ❑ Distance to nearest lot line-------------------------------------------------------- --.......................................... --------- ------- - <br /> Remodeling anti/or repairing (describe):--------------------------------------- .........................................--------------------------------------.. ................... <br /> ------------ -------­-­-------------.----- ...................... -------- -------- ------- --------------------- ------- ------- ------- ------••. ....... -------- ------- --------- <br /> 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 regulat ns of the San Joaquin Local Health District. <br /> (Signed) //;",I ° -.-----------____________ __(Owner and/or Contractor) <br /> BY:----------------------------------------- ------ --- •----------------------- ----------(Title)---- ------------------------------------------------------ <br /> (Plot plan, showing size of lot, loc of system in rel n f ells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ------ - ------ ---- - - --- ---------- DATE-------------------------- !"' ----•-• . <br /> REVIEWED BY ..-._. DATE------- �' -- ----I---- <br /> BUILDING PERMIT ISSUED---------------_------------ <br /> -----A---- ----• ----- DATE. ------------------------------------------------Alteratio s nd/or recommendation <br /> ti*-—------- <br /> �"'-�- -- -d-- i --•-100 51040 <br /> ' <br /> tom` •-- ------ - ------•--------------- ---- -------------------------------------------- --_----- --------- <br /> .. •-----. ---- - <br /> FINAL INSPECTION BY:_ f [ .- Date......... .....-._. •-....__ - ---- ------- --•-- <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 8-51 Revised W-2100 <br />