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l� <br /> APPLICATION FSANITATION PERMIT Permit No. ....1�1r_7._ <br /> Z (Complete in Duplicate) <br /> Date Issued ----------------------- <br /> Application <br /> _----_------- ----Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is applica4ion is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS OCATION-------y/•� -- - -- -------- ;`' ------------------------ 'f"-0.0'Ir <br /> Owner's Nam __� . . ------------ ----- -------- -------- Phone-- -- <br /> Address- -•• ... ... . --- ......--•-- <br /> Contractor's Name.............. .. ------------------------- Phone--------7.... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of baths ---/--- Lot size .-Get. --4...........:...................... <br /> Number of living units: __,,/_-_ Number of bedrooms____ <br /> Water Supply: Public system ) 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.)ff Hardpan ❑ �. <br /> Previous Application Made: Yes ❑ Nox New Construction: Yes ' No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation•--__________--•---.Material___--___-_-_._-_-____----------___---_._____:.. <br /> No. of compartments-------------------------Size-------------------------------Liquid depth-------------- -----------Capacity-- ------ <br /> —li <br /> isposal Fie : Distance from nearest well.--------------_Distance from foundation....................Distance to nearest lot line----------------- <br /> Number or lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Type of filter material_________________________Depth of filter material----:---------.--------Total length-------------------------------------- --_ <br /> If <br /> Seepage Pit: Distance to nearest well Distance from f undatio __4�__..__...Distance to nearest lot line-___ __-__--_- <br /> —�``------ <br /> Number of pits.----/---------------Lining material Size: Diameter-_..7.-----.--__.---Dept h---a ____________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> 0 <br /> 1­71Siza: Diameter--------------------------------------Depth---------------------------------------------_-_._Liquid Capacity•------------------•-------•gals. <br /> �T rivy: Distance from nearest well-------------------------------------------------Distance from nearest building-----..-__-.-__:.-.•__-______---_-.----:=. <br /> ❑ Distance to nearest lot line-------------------------------------------------- ----•---•---------------------------------------•-----------•---•--•--------•----------- <br /> Remod mg and/or repair' be):___.__. _ <br /> --- . •... - ----•-- -- --- -- <br /> --•--..........,.... <br /> ---------• --------•------ ..... <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------•----•------------- <br /> I hereby c tify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta t laws, les and regulations of the San Joaquin Local Health District. <br /> (Signed) ` --------------------------------------------------- (Owner an r Contractor) <br /> ......Zile-, <br /> By:.................................. fi'`. -----------------------------------------------------(Title)......... _ a 7:--- -•-•• <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pl d on rev a sid <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------•-------------------------------------------- ------ DATE--------------------------------------------------- <br /> REVIEWEDBY----------•-•......---•-•---••- --- ------------ ------------------------------------------------- --------------- DATE-----e................................................... <br /> BUILDING PERMIT ISSUED------------------------------------------------------ <br /> --------------- ---------------------------•-- DATE------ ----------------------------------------------- <br /> Alterations and/or recommendations------------------------------------•----------------------------•..........................................1�---....-•-•-•---•----•--- •-•----------•-.. <br /> F ----------------- ------------------------------ ----- ............................................ <br /> --- ------ - -- ------ - <br /> -------------- -----� <br /> ----------- --- ---- <br /> -------------------- ------- ----------------- -------------------------------------------- <br /> ---------------------------------- <br />-1-AINAL INSPECTION BY:.- --- ------ --------------------- 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 10-52 Revised W-2100 <br />