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FOR OFFICE USE- <br /> -- ------- -- ---------------------------- ---------- Permit No. <br /> -------- - -- <br /> APPLICATION FOR SAKITATON PERMIT <br /> - ----- <br /> -- <br /> --- -_ -- --..-- (Complete-in Duplicate) Date issued ----� -�� <br /> This Permit Expires 1 Year From Date Issued <br /> - <br /> ----------- r <br /> Application is hereby made to the San Joaquin ;Local Health District for a permit to construct and install the work herein described. i <br /> This application is made in compliance with County Ordinance No. 549. l <br /> "" " "" •---------------------- ------------------------------- <br /> L'JOB ADDRESS AND CATION.. 7ir <br /> LV I r Phone---.I---------------------------•--- t <br /> Owner's Name- ----- - ------- f <br /> Address_-------� �� --�---•--- ----------•---------- -•------ <br /> r s one ..----- <br /> Contractor's Name ts.1 Ph ... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units. __/-_._ Number of bedrooms <br /> Number of baths ---- Lot size ._-- --- ---------- <br /> Water Supply: Public system El Community system ElPrivate [?5-*"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; .P(if yes,date...... .......... ] No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: -�—' -�-- <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> p of compartments -----------Distance from foundation_.-..-..--------__-Material . .....--.-...-..------------------------------ <br />� <br /> Septic Distance from nearest well"....__.".� , <br /> ❑ No. ...-- Size--------- ----------- ----------Liquid depth------- : Capacity.. <br /> p .�. � <br /> a t. � <br /> Disposal Field: Distance from nearest well..._..-_-_.....Distance from foundation!..."...............Distance to nearest lot line...-.-_.-......_. <br /> G ❑ Number of lines.-�---:--`:--- -----------1-- "Length-of each-line----------I------------------Width of�rench...- - -------------- ---------•-- <br /> ,. ,� <br /> r Type of filter material----- _-----:-----.Depth',of filter material-_-`...:_:_"y.".-_Total 'length......... ............" .-......_.'_.-. <br /> See pa Pit: Distance to nearest well ~......__..:-,- _aDistance from foundation'.... Distance to nearest lot line__..`_...... v <br /> 0, i <br /> Number of pits--- --f.__-.-.------Lining 'mate idl""" �/''_"Size: Diameter...- :.-_- _ Depth- ------------:----------------- <br /> Cesspool: Distance from nearest well ------------ ---Distance from foundation.---------------- --Lining material--.--'.-.---------------------------- <br /> ❑ Size: Diameter. .- ----- ---------- ----Depth--------- ---------- ----.-Liquid Capacity---.I------------------------gals. <br /> s Privy: Distance from nearest well---................_----_.:.__.----------------Distance from nearest building---------- <br /> F- ._".__-_-.....----.-...... <br /> ❑ Distance to nearest lot line -------- ------ ------ --------------------------------- <br /> 1 Remodeling and/or repairing (describe)------ ------------ f----------------- -- ---------•-•------- •---••-•---------------- <br /> i ------------------------'--- - ----------- <br /> ------------------------ ------------- -- <br /> t <br /> -------------------------------------------------------------------------------------------- ----- <br /> ------------------------------------------------ -------------------------------------------------------- ---------------- <br /> ---------------------------------------------------------------------------- ------ - <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, Stat ws, and rules and regulations of the San Joaquin Local Health District. i <br /> i (Signed} -- --------- -- ----------------• - ------------------ -----------+Dwme"nd/or Contractor) <br /> Title -.- <br /> Br--------- (Title) i <br /> l' (Plot plan, showing size of lot, location of system' in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> APPLICATION ACCEPTED BY -- - - ------------- --- --------------------- ------------- DATE---/--~�� .' ' - <br /> REVIEWED BY-------------------------- -------- ----- - --- ---------------------------------------- --------------------- DATE-- ....... -----------------------------------•----------- <br /> - -- - - -- - -- <br /> BUILDINGPERMIT ISSUED-------- -- ------------------------------------------------------------------ ------ DATE---------------------------------- ----------- -------- <br /> Alterations and/or recommendations:----------------- ------- -------------------------.-....----------------------------•------------------------------ <br /> ----------------- -----"---------------- -------------- --------------------- <br /> ----- <br /> a <br /> i s FINAL' INSPECTION BY: .- Date--Y -------- -fib - - - ---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 20.5 West 9th Street <br /> Stockton,California Lad!, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />