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` " I APPLICATION FOR SANITATION MI 5 <br /> � ON PERMIT Permit No_ --- --- <br /> (Complete in Duplicate) <br /> Date Issued ------------------'S Z <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 Ordina Sr ce No. 9. <br /> I <br /> JOB ADDRESS A D LO�ATaGN : - -_.-- <br /> [ --------------_ -------- <br /> Owner's Name__ <br /> - --------------------------------------------------------------•-------------------- ---------- Phone_,Z,- - <br /> Address--- ^- — <br /> ----------------------------------------------------------- ------------------------------------------------•---------------------------- <br /> Contractor's Name------- ­---------- -t -----. Phone <br /> - --- --------------- -------------- -------------- ------------------------------------------- ------ <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: _1.____ mber of bedrooms __Z_ Number of baths ---/--- Lof size _-___f_-_ _ -_ t <br /> A i <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 Hardpan ❑ <br /> Previous Application Made: Yes ❑ Na New Construction: Yes No ❑ (� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted Pf public ewer is available within 200 feet.1 I <br /> s / <br /> Septic nk: Distance from nearest well __ Dista a from fund bn-___ Mat i <br /> •� k 1iX j, �l - •- --- <br /> No. of compartments----------- ------ -Size- ------------ t q ' }} <br /> ------•-------.Liquid depth-------•-----------------Capacity_!±l_!__470._ <br /> Dispos Field: Distance from nearest well.-`__a--____ .Distance from foundation___+�- Distance to nearest lot li <br /> Number of lines_=_______ _ Length of each line---------����_�Width of trench__________ <br /> -------------- <br /> OT <br /> Type of filter materi _!__-t--___-____ _Depth of filter material-------�_- -___:___Total length-_______ -/-/--- ---_ <br /> ---------• R <br /> Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line----------------- <br /> F-1 <br /> Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h------_------_____-___--_------_ <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-,-------------- <br /> Size: Diameter____,.--------------- ---------------Depth--------------------------------------- -----------Liquid Capacity -- gals. <br /> - - - --------------------- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building = <br /> ❑ Distance to nearest lot line------------- ------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------- <br /> ----------------------------•--------------------------�----•--------------------- --------------•--------------•--------------••-------••--------------------------------I——--------------------------------- <br /> ----------- <br /> ------------------------------------•---------------� --•---------------•----•-----••---------------------•--------•--------------•--------------------------•--••------- <br /> - her- - --------•----------------------------------------------------------------------------------------•-------------------------------- 1 <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, Stag awwand rules and regulations of the San Joaquin Local Health District. <br /> r . <br /> (Signed) :- 'r ---------- <br /> '`' --- <br /> -------------- <br /> - caner and/or Contractor' <br /> By:-------------------------------------------- - --- ----------------------------=------------------------------------------- Tale __________ <br /> (Plot plan, showing size of lot, locat' n of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_Q-_------ - --- ------------------------ DATE:45'_ <br /> - ---- - - ------- ------ <br /> ---- - -------- --- - <br /> - - <br /> REVIEWED BY F - ----------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED------ `ZJ <br /> --- -- ----------- DATE-- <br /> ------------ <br /> Alterations and/or recommen af,pons------ ----- --- - -----•------ <br /> - t -- �-- ------ -C -----­J­ --- <br /> YF <br /> - <br /> -- : <br /> --------- t <br /> ------------------------------------------------------- ------------------ - -- ----•- ---------------------------------- <br /> . <br /> c ----•------------ ------------- <br /> FINAL INSPECTION BY------------------------------------------------------------------ Date <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT,- <br /> 130 <br /> ISTRICT-138 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California l <br /> ES <br /> =9-2M 8-51 Revised W-2100 <br />