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Lt V1 <br /> APPLICATION FOR SAMITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Hea{th District#or a permit to construct and It+stall the wo k herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ��yy <br /> JOB ADDRESS AND L ATION 1.'_! - ---------.................. --- ---- <br /> Owner's Name------------ --- ----- ---------. --------- ------- - - Phone - <br /> Address--------------dt�__.ly ---------- . ------ -------------------__- ----- -----' ----kms=`"------------------------------• --- ---------------- <br /> Contractor's Name---------------------- ------------------------------------------------------------------------------------------------------------------- Phone.--------------------------------- <br /> Installation will serve: __Resident [$ Apartment House ❑ Commercial ❑ Trader Court ❑ Motel -E] Other ❑ <br /> Number of living units: I Number of bedrooms 0 Number of baths � Lot size--------ZA --- ---------------------------- <br /> Water Supply: Public system ❑ Community system Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [X Adobe❑ Hardpan ❑ r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public ewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well--- - .0---Distance frorp4oundation <br /> � Matel_ <br /> ... _No. of compartments--------- ---.Size... l Liquid depth ---- _� <br /> � I ",_; <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> F1 <br /> ----- _-__-_ -._-_--._ -___❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Q <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-______-----------_---__--__-____-. 0 <br /> ❑ Distance to nearest lot line------------------------------------------------ <br /> Seepage Pit: Distance to nearest well------_---------------Distance from foundation-----------_--------Distance to nearest lot line-._----_--_..---- <br /> ❑ Number of pits----------------------Lining aterial------__.-_--___-------Size: Diamete ------------------------Depth-----_ <br /> - -_._--------------------- <br /> Disposal Field: Distance from nearest well -T Distance from found t' f <br /> Number of lines--------------Ai _---_______- Length of each line._{__ lY' .._Width of trench-----�.................... <br /> Type of filter material___-__1 epth of filter material_ _-_1A...... <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------•--------- -------- <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--�----� • (Owner and/or Contractor) <br /> By:------- -------------------------------------------------------------- <br /> ----(Title)-- -------------------------------------------------------- �T <br /> (Plot plans, showing sue of I t, lot io of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------- ---------------------------- --------------------------------------- DATE--------- ---------- - <br /> REVIEWED BY DATE - <br /> SU&-DMG PERMtT ISSU€D-------------------------------------- --------------------------------- DATE------------------------------------------------------- <br /> AJferafoons and/or recommendations------------------_-- -------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------•-----------•------------------------------------------------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ___________________________________________-------------­----- ------------- <br /> __________________________..--------------------------_--_-_-__ ---_ - ---------------------- <br /> PERMIT No ._ ._ ISSUED..._ ../J4 .3....._.._._(Date) FINAL INSPECTION BY:-__ -.-- ..___.._ . ---___--._- <br /> Date----------_....----- .91 . �---- ----------------- <br /> SAN JOAQUIN LOCAL FEMTH DISTRICT <br /> 130 South ,American Street <br /> clrtent, C446ftia <br /> ES-9-2M 9-50 W=1639 <br />