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rUKUFHCE USE; <br /> - --/ lvj p <br /> --------------------------------------------------------- APPLICATION FOR" ANITATION PERMIT Permit No. ____ _- 3 <br /> ------------ ----------- ------- <br /> ---------------- (Complete in Duplicate <br /> --- This Permit Expires T Year From Date Issued 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 /> L <br /> JOB ADDRESS AND OCATION.____J�'-'�_ <br /> z 1 - --------- -_: -1�------ �r�r J�:----------------- '� -------j <br /> Owners Name r - Phone- --------------------••------••---- <br /> Address = �f•H f��� / ------------- 9r% k---------------------------=------------------------------- <br /> ------------------------------------ <br /> Contractor's Name---------- --•---------- -- --------k---------------- -----------•-------------------------------------•------------- Phone----------------------------------- <br /> j� <br /> Installation will serve: Residence Apartment House ❑ 1Commercial ❑ Trailer Court E] Motel ❑ Other El <br /> Number of living units: _!_----- Number of bedrooms ---�7_ Number of baths _!9t Lot size ....�--;�_.: <br /> Water Supply: Public system E] Community system E] Private Depth to Water Table _ __._ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 4 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date-------------_------) No Qom' New Construction: Yes' No ❑ FHA/VA: Yes ❑ NOV <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 welt'__ _____Distance from foudation--___b2-_______ Mat�efi L, a C' L— --- ---------- <br /> fNo. of compartments_____-- -----------Sily_ ___y -------------Liquid depth---------- ----.---Capacity_____ <br /> Disposal Field: Distance from neares.well__ 0-.--_--Distance from foundation__--------Distance to nearest lot line._ <br /> Number of lines------- ------------------------•--Length of each 1i4 <br /> -- 777� /Jidth of trench_ ------------------------- <br /> Type <br /> ----•------------------Type of filter material=a_17-rh^ r Depth of filter material----�c �-(-------Total length_____A-7-61 <br /> -- ------------- <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 /> �. <br /> ❑ Size: Diameter------------------------------ <br /> ----Depth--------------- ------- -------------------------.Liquid Capacity----------------------------gals. ; <br /> Privy: Distance from nearest well-___________________Y-___________._._____ ._Distance from nearest building_______________________--__---_-----___. w <br /> ❑ Distance to nearest lot line-------------------------- <br /> } <br /> Remodelin and/or repairing describe - ------ __ <br /> -----•---•- - --------------------------- ----- <br /> ------------------- --------I----------------------------------------------------- <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, nd rules an regulations of the San Joaquin Local Health District. <br /> '' <br /> (Signed) , . _= gi d ..----------- - - - L (Owner and/or Contractor) <br /> By:_... ------ - ----------------------------------=-"--------.------------------ ---------(Title)-- --------- ----------- - <br /> (Plot plan, showing size of lot, location,.of.sysfem,in,relatio to wells, buildings, etL, can be placed on reverse sir). <br /> FOR DEPARTMENT-USE ONLY <br /> APPLICATIONACCEPTED BY------------------------------:------------------------- ----------------------z-------- DATE-------=--•-------•------------------- <br /> REVIEWED BY -------- DATE--- - <br /> BUILDING PERMIT ISSUED_____ <br /> ��J <br /> ---- -------------- DATE------------------ ------------------------------------------ <br /> Alterations and/or recommendations=-------------------------------------------------------------------- -•----------------------- X <br /> -----------•-------------------------------------------------------------------------------------------------------------••------------------------------------------------------------------------------------------------ <br /> ---------------------------------•------•-•----------I-------------------------------------------•-----------------••----------------------------------•---•-------------------------------------•------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------•---------------•----------------------•---------------------------------------- <br /> ------------------------------------------­------------ ---------------------- ------------------------------••----- <br /> FINAL INSPECTION BY:..,- <br /> Y:. Date -c -,•----C ------ ------------------------------ <br /> SAN OAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Hazelton Ave. 3 5- 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California 7/�1/YYYF/�. Lodi,California Manteca,California Tracy,California <br /> CS 9 REVISEo a-54 3M 3--63- <br /> � N <br /> • f7 I <br />