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FOR OFFICE USE: <br /> j� - ----� <br /> - ------------------------------ <br /> -------- <br /> --____...__.___________ ----------------------- APPLICATION FOlt SAMITATION PERMIT Permit No. _ 1................ <br /> ----------------- (Complete in Duplicate) <br /> - This Permit Expires 1 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 /> JOB ADDRESS AND VCAN_-,f_l S-'r-__� / i �' � ? -----fito`""�_-Owner's Name------•--� -- - ------------ -------------------------------- Phone------------------------------------ <br /> Address------------ <br /> -----------------•---•-------_-----Address------------'' ................Pr -- •-- -•-- ---------•- ............. <br /> Contractor's Name--•-------�----- -• ----- - -- -------•--- r'e'f Phone- <br /> Installation will serve: Residence` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/_ Number of bedrooms %?-_ Number of baths __l__-_ Lot size -_-_.' Q _.X_.:,i'Qca'_________________ <br /> Water Supply: Public system ❑ Community system ❑ Private 0( 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: (If yes,date. ------- ----------) No k New Construction: YesX No ❑ FHA/VA: Yes ❑ N0,W <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_ d.____Distance from foundation_._/__# /-_--.Material_-_ <br /> No. of compartments___.__oZ----------___Size ___Liquid depth___ '-.______.____CapacityZ0a4W6W <br /> Disposal Field: Distance from nearest well._�� -----/ - <br /> Distance from foundation./.0J__'__---.Distance to nearest lot line_�.f_-__ <br /> Number of lines._-.____---. _-_ -_-_zz Length of each Width of trench---- <br /> -------------------- <br /> .10, <br /> Type of filter material--- - Depth of filter material---/.9'___:".__._Total length-----/------------------------ <br /> Seepage Pit: Distance to nearest well__/Qs7__--___Distance from f undation__,lV-_---.__--.Distance to nearest lot line__L1____ <br /> jkNumber of pits.... ----------Lining material._ __...Size: Diameter----ti7---q-----------Depth------JI-�_`-.._-_-_-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----.---------------Lining material------------------------------------- <br /> ElSize: Diameter--------- --------------------------Depth----------------------------------------------------Liquid Capacity---------------------------.gals. <br /> Privy: Distance from nearest well------------------.------------------------------Distance from nearest building----------------------__•_____---.-.---._. <br /> ❑ Distance to nearest lot line----------------------------- --------------- ----------------------------------------------------------•---------------•------- ------- <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------- --------------------------•-- -------------------------- 4 <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 regulations of the San Joaquin Local Health District. <br /> (Signed)---------------------- -------- --------- ------ --- --------------------(Owner and/or Contractor) <br /> or By:-----------C * Title) <br /> ---- ---- -------- <br /> (Plot plan, showing size of lot, location of sy em in relation to wells, buildings, etc., can be placed on reverse side). <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- - --- ------------------------ <br /> ------ DATE------ - '��--------------------------------- <br /> -- ----- - - <br /> REVIEWEDBY------------------------------- --- --------- ----------...--------------------------------------------- DATE---------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE.-------------------- --------------------------------------- <br /> AlIeati 75. �/or ---comm`- -----------a..l.,------�� ` ;--------------------------------------___-------------------------------------_..-------------------------------- <br /> /�? <br /> ------------------------------------------------------------------------------------------------------------------.-_--------------- ---------------------------------------•------------------------------------------- <br /> ­-------------------------------------------- <br /> -------------------------------------------------------------------------------------- ---------------------------------------------- ---------------- ----------------------------------------------------------------- ------ <br /> ----------------------- ------------------------------------ - --------------------------------------------------------------•---------- <br /> FINAL INSPECTION BY:.... rE -------- -------------- Date---- / .=U �} ----------------------------- ---- .._. <br /> SAI�i JOA UIN LOCAL HEALTH DISTRICT <br /> 4 <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 /> F.P.CO. <br />