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FOR OFFICE USE: <br /> - --_- --.._. /� APPLICATION F0�ANITATION PERMIT Permit No. <br /> ------ -------- <br /> (Complete in Duplicate) Date Issued _)t 7-=---- <br /> This Permit Expires 1 Year From Date Issued <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 /> rE� ( pGG�71 <br /> ---------------- <br /> JOB ADDRESS AND LOCATION . - Phone-----------------------•------------Owner s Name- ---- ------ ---------------------------- <br /> Address--------- -------- -------------•----------- -----------•---------------------------- <br /> S �S Phone----------------------------------- <br /> Installation <br /> Name--- - ----------------- ------- ---- -- --- --------- -----------•----- <br /> - - --------------- <br /> Installation will serve: Residence [.}Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel' ❑ Other ❑ <br /> Number of living units:. J--- Number of bedrooms -_ - Number of baths -_.L-- Lot size ----- tyx --------__ <br /> Water Supply: Public system ❑ Community system ❑ Private [3�- }�ept}h to Water Table -20- ft. <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand F-1Gravel ❑ Sandy Loam ElClay Loam ❑ Clay ElAdobe In--_Hardpan <br /> Previous Application Made: (If yes,date--------- -.------- ) No RR'-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 /> Septi ank. Distance from nearest well----_-----_-----Distance from foundation--------------------Material------ ----------- ------------------------------ <br /> No. of compartments- - - -------- ----------Size--------------------------------Liquid depth---------------- ----Capacity------ --------- <br /> Disposal N Distance from nearest well,61.*--._..Distance from foundaflon./49*_.__---_.Distance to nearest lot line--- --_----- <br /> Number of lines.;-._Y---------- -----------------Length of each line-`-------------------Width of trench.------Z-.9__"-__.---..-------- <br /> Type of filter material_ �_��C'------Depth of filter material.._-� '_`� ...Total length-------- --`--•--------------------- <br /> 3 � � i <br /> Qistance to nearest well '---Distance from foundation--lb.--___.-___.Distan`e to nearest lot line <br /> Number of pits....t_--------------Lining material.l .�-k-----.Size: Diameter--.-_'9� _.-----De th___...Z-Z .-__--------------- <br /> Cesspool: Distance from nearest well ----------------Distance from foundation-------I-----------Lining material------._.----_.__-------------• ---- <br /> als- <br /> ❑ Size: Diameter- --- --------- ----- ----------------Depth----------------------------------------------------Liqu;d Capacity_-------------------------g <br /> Privy: Distance from nearest well-------------------------------- <br /> ------------ --Distance from nearest building----- -------------------------------------- <br /> ❑ <br /> Distance to nearest lot line------ --------------- -- - --------------------- <br /> ---------------------------- ----------------------------------------- <br /> Remodeling and/or repairing (describe)-------------- ------------ - -----------------•----------------- -------------------------------------- <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, State laws, and rules and regulate s f the San Joaquin Local Health District. <br /> - -------------- <br /> (Signed) - - <br /> ---.---____---.-___(Owner and/or Contractor) <br /> ------------- <br /> ------------------------------------------------(Title)---------- ------------------------------------...------ <br /> (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 /> APPLICATION ACCEPTED BY-_ ..... <br /> .-- ---- ------ <br /> DATE <br /> ------ - -"'�' -------------------------- <br /> REVIEWED BY-------------------------------- ----- ------------ ------------------------------ ------- ---------- <br /> .- DATE------ ------ ---------------------------- -------•------- <br /> BUILDING PERMIT ISSUED---------- --------------- -- - -------------- - DATE------------------------------------ --------------------.... <br /> ------------- <br /> -------------0- --, <br /> Alterations and/or recommendations___________ __ �-LL ----•----------------------------------------------------------------------------------- <br /> ----------- ------------------ ------------ <br /> ----------------------- --------------------------------------------------- -- -------------f-- .a"-- ------- ---------- ---- ------------ ----- ----- <br /> ---------------------- <br /> 0 <br /> FINAL INSPECTION BY------ ---- ---- ---- -- -- --------- <br /> --------- ' ------- - Date.------ ------- -- ----------- - --------------------------------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California, Manteca,California Tracy,California <br /> r <br />