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/ a/ <br /> ' APPLICATION FOR__ANITATION PERMIT Permit No. --- _ <br /> (Complete in Duplicate) <br /> ri T Date Issued -- <br /> rlpplica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> his application is made in compliance with County Ordinance No. 549, <br /> JOB ADDRESS AND LOCATION-_____E_y __ _ _____ <br /> _ _ -------------- <br /> Own4--- ----- <br /> er's Name------ ------------------­-r1 `-•--- " •• - { Phon �� k?&...�-- <br /> -- <br /> Address-------------L---------1-- ------�-- <br /> - - --------- <br /> Contractor's Name � ---------------------------------------------------------------------------------- Phon ----4_--- ia:' A <br /> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ otel ❑ Other ❑ <br /> Number of living units: _______ Number of bedrooms ._Z. Number of baths _�_ Lot size __ L�___�__�' _______ <br /> Water Supply: Public system P-.-Community system ❑ Private ❑ Depth to Water Table -------- ft. ` <br /> Character of soil to a depth of 3 feet: SandGravel L] Sandy Loam Clay Loam El Clay El' "Adobe Q'-Hardpan <br /> E y <br /> Previous Application Made: Yes [I No Now Construction: Yes No ❑ r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ; <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.),,. W <br /> Septic Tank- Distance from nearest well_________________Distance from foundation__.__.a_____ .Material___-_t_;-_._____.____.______________________- <br /> No. of compartments-------------------------Size--------------------------------Liquid depth----------------- ,Capacity------- <br /> Disposal Fi d: Distance from nearest well------------------Distance from foundation-------------------- to nearest lot line_______...___.__. <br /> Number of lines------------------------ ----------Length of each line------------- --------------Width of trench----------------------------------- <br /> Type of filter material---------- --------------Depth of filter.rm`aterial___________-___________Total length------------------------------------------ <br /> Seepa e Pit: Distance to nearest well_ ^ __________Distance from foundation----��-.a--__-___.Distance to nearest lot line----- <br /> ` y___ <br /> 19 Depth---2r-------------------- <br /> Number of pits.---- .___ <br /> .__..___ ._.Lining material�� �Size: Diameter_______�-__-__------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------.__.___________________- <br /> �� ❑ Size: Diameter----------------------------------F_-Depth----------------------------------------------------Liquid Capacity---------------------------gals. <br /> �T <br /> Privy: Distance from':nearest well-------------------------------------------------Distance from nearest building__________._______________________________ <br /> ❑ Distance to nearest lot line. �--------------------------------------------------------------------------'---------•------------------------------------ <br /> l <br /> Remo eling /or repairing [deer':E,e�F__'__ M�------ -- ------- ' :_ -- LeS � ---------.--- <br /> r . . <br /> ............. .•--- ---- •--------------- ------------------------------------------------- <br /> - ------------------------- -------------------------------- <br /> a , <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.-------------------------------- <br /> I hereby certify that I hove prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rulesand regulations of the San Joaquin Local Health District. <br /> (Signed)------- i _ �=--'--------*'------`-------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By� ----- : :. (Title) -'--------------------------------------- <br /> (Plot plan, showing si of lot, locati n of system in relation to wells, buildings, etc., can be placed on reverse side]. <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----------------------------`--------------------•---•-------------------- DATE -------------------------------------------------- <br /> ------------------ <br /> DATE-- '„_... ' <br /> REVIEWED. i3Y r.: --=-=-------------- -- ----------------------------------------------------- -------------•------------------------ <br /> BUILDING`PERMIT ISSUED --------------------------------------------------------------- t'``= =_ DATE --------------------- <br /> --------------------------------- <br /> Alterations and/or recommendations______________________ ______ 1 - i � ' <br /> ---- ------------------------- --------------------------------------------- ---------•------------------- <br /> i <br /> ------------------------- - � ,(' --•--- ... - <br /> ------------------- <br /> ---- <br /> -- 1�------ ------ ----------------; ------------ ----------------------------------------- ..... -------......... <br /> !F <br /> FINAL INSPECTION BY----------- ----- �- ------------•----- Date......4----------------------------- <br /> --- ---------------------------------- <br /> SAN JOAQUIN LOCAL--MEALTH 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-4-2M Revised W-2100 <br />