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'?LICATION FOR SANITATION PE(`4?T Permit No. ` <br /> (Complete in Duplicate) <br /> Date Issued 'L.3..s_=T <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 County Ordinance No. 549. <br /> r <br /> JOB ADDRESS AND LOCATION__..__..1Z-0- ------�#-----------'----==��-------- ----°'� ----------------------------- ----------• ---------------- <br /> Owner's Name -�` I <br /> Phone ------------- <br /> - . <br /> Address - . --------------------- ---- ' ' <br /> a.. <br /> ----------------- ----- <br /> Contractors Name---------------------•- --------•-��--------- - -'''L•� __. �.�.r <br /> ----.._..._ =-•--------•--------------------•- <br /> Installation will serve: Residence I Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: __ ----- Number of bedrooms __�_�Number of baths .�___. Lot size -------.{..___ <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 Oj—,fardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes Ej,-No ❑ <br /> .TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 4 <br /> Se Tank: Distance from nearesf.well-_ :_Distance from foundation---_ __. __.Maferi I__________________ ___�_...___ .._----- <br /> _--- <br /> Septic <br /> of compartments----------------------Size----4Z_s�X__ _Liquid depth---------- ---6r capacity------.�_�_�-�--- <br /> s ora <br /> Dil Field: Distance from nearest well--_..` 'l.+1_Distance from foundation_____f Q-_---._-Distance to nearest lot line------- W <br /> Number of lines---------- __ -_-- Length of each line----------- <br /> 6------------Width of trench._.---.___-�_4�_.-L___ G <br /> r <br /> Type of filter material -_-___-_-_Depth of filter material-------/ `-.___._Total length_____________________!__ G?-7----- W <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation___---------------Distance to nearest lot line---_-_--..------_ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth_--------.----------------------- ' <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_.._.__-______.....________..___-__ <br /> Size: Diameter--------------------------------- ----De Depth----------------------------- ---- <br /> ❑ p_ -:_Liquid Capacity------------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________________----____---------__ <br /> ❑ Distance to nearest lot line--------------------------------•--------------------------------•----- <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 /> 1 <br /> (Signed l ":. . r--------- - ------(Owner and/or Contractor <br /> �t / ) <br /> BY' ------------------- ----- ----(Title)-------------- ---- -------------------- ------- ------ <br /> Plot plan. <br /> owin size of�tLcation of s stem in relation to wells, buildin s etc.,( p g � y buildings, can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY } <br /> APPLICATION ACCEPTED BY----. <br /> ------ 1' a --------------------- DATE <br /> ------------------ -----REVI> WED BY l ---------------------•---------------------------------------• DATE---.---------- ---- <br /> BUILDINGPERMIT ISSUED----------------------------•--------------------------------------------------•-------------- .------- DATE.----------------------------------------------------------- <br /> Alterations and/or recommendations:-•----- ----•--------------•---------------------------------- ------------------------------------------- <br /> -------•--I-----------------------•------------------------------------ - --------------------------------•--------------------------------------------•--------------- ----•------------••-------------------------------- <br /> --------------------------------------------------­-.__­------------------------------------------ ----------------------------- <br /> -------•-----------------------•-------•-----------------------------•---------------------------------------.-....-------------------------•••---•-------------------------------------•---------------•------------------- <br /> -------------•---•--------------------•---------------------------------------•----------- ----•--------------------------------------------------- ------•----- ------------------------------------- ---------------------- <br /> FINAL INSPECTION BY-------------- -•---------------------------------------- Date-----------------------QJ--µ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California .04 4i Tracy. California <br /> i <br /> ES-9-2M 10-52 Revised W-2100 <br />