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16 q is 7 /�i�,z�� / � � <br /> KATION FOR SALTATION PER Permit No. _.. ._..... <br /> (Complete in Duplicate) ��` DWIDate, Issued _� ___ __ � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons ru and ins all the work herein described. <br /> This application is made in compliance with County Ordinance No. 49 r D �0A1 <br /> JOB ADDRESS AND TION........ --1] �••--- �� <br /> - ---- -----•------------ --------- -•- -- <br /> Owner's Name............. •- -- ------- Phone__ <br /> _.. ------- <br /> Address---------------------------- -------•--• ........ --- ------------ --•---- ---- ---- --------------------- <br /> Phone_ <br /> Contractor's Name...............................------------------------------ - ------ 6 <br /> -------------------- --�--- <br /> Installation will serve: Residence ❑. Apartment H se ❑ Commercials Trailer Court ❑ Motel El Other [-]'Number of living units: Number of bedrooms _ Number of- baths •___ Lot size .....3.../Y( '1 .�__________________________ <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 x Hardpan ❑ <br /> Previous.Application Made: Yes ❑ No X_ 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 /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__________-______ <br /> ❑ Number of lines___________________________________Length of each line------------------------------Width of trench-_-__________________-________-____ <br /> Type of filter material_________________________Depth of filter material___-__________._-_-__-_Total length___-____-_:____________-__________--------- <br /> Seepa a Pit: Distance to nearest well_--Q4 __.;.Distance from�f,o�ndation___�t___._____.Distance to nearest lot line__4Q-�-__ <br /> Number of its_ 1' �___Linin material_,&.. ',-Size: Diameter_--.33�� <br /> p 9 - --• --------.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 /> �� • <br /> Remodeling and/or re airing (describ ----- --- <br /> - ------- -- -- <br /> - ------ _ -------f <br /> ---- -----------------•--- ---------------- -------- ----------------------------------------------------------------------------------------•-------------------- --------------------------•---- ------------------- <br /> I hereby certify that I ve r pared this applicatio and that the work will be done in ac r ante with San Joaquin County <br /> ordinances, State laws, an rule d regulations of t San Joaqu' cal Health District. <br /> (Signed) .. ----- - ------- - ---------- ------ ------- <br /> By: <br /> (Owner end/ Cont ctorJ <br /> By:----------•------------- ----- ---- --•• --- - ---- -------- - - - - •- - 1.�------------------(Title)--------- --- -------- <br /> (Plot plan, showing size ocation of system in re at on to wells, buildings, etc., can be pla on reverse side). <br /> FOR DEPAR ONLY <br /> APPLICATION ACCEPTED BY----------------------------------------- ________it_Cv DATE._-_____:.._.___ /l __ <br /> REVIEWED BY--------------------------------------------------------- DATE----------- <br /> --- --------------------------------- � -- - <br /> BUILDINGPERMIT ISSUED---------------------------------------------- -------------------------- .....--------•-- DATE------------------------------------------------- <br /> Alterations and/or recommendations-----------------------------------------------------•------------------•-------•-------•-••----............................................................ <br /> .............................----------------------------------------------------------------•------------------------------------•-••-••-------•-•••------------•----••-----------••----------------------•-•--•-••-•------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------- <br /> -----•---------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------ <br /> ----------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------.._---- <br /> FINAL INSPECTION BY:--_-._-U_� �------------ Date_------...... <br /> ---(-_-------- e�_ ---------------------_---- <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 />