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FOIZ--OFFICi USE: <br /> -------------------------------------- <br /> ILICATION •FOR $AMTATION PERMIT Permit No. .. 1 � <br /> -_ (Complete•in Duplicate)---_ <br /> Date Issued ._rf.2' ; <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 /> JOB ADDRESS AND LOCAT ..... ) -------------- <br /> ----------------- <br /> Owner's <br /> ---•--------- <br /> .►�/ <br /> Owner's Name---!___/__/2..__-•---��--�/� yr----------------------------- -_---- - --------------------- <br /> AddreAddress <br /> ss------------------------ -------- ------ ----------------------------------------------------------- <br /> �, e <br /> Contractor's Name____ _ _ �> / - \ <br /> a- l� ------ Phone.?,V-- ---- <br /> Installation will serve: Residence ❑ A artment'House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ er R111, <br /> p � <br /> Number of living units: -- ----- Number of bedrooms -------- Number of baths--/-- Lot size -----%- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ----- _ ft <br /> Character of soil to a depth of 3 feet- Sand 01 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (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 /> Septic Tank: Distance from nearest well _.__Distanc from foundation------1_P-__--.Material .&.C?��k 1--'�__________ ------ <br /> No. of compartments_-____ ,_ <br /> ........ .Sizer '�__wV ------Liquid depth__s - ..-__ Capacity___ d_____.__ <br /> Disposal Field: Distance from nearest well--,,�._. _Distance from foundation--- ---------Distance to nearest lot line.... <br /> Number of lines._-___.__ _- - - Length of each line__ --- M__.._-__ Width of trench._.Z_ ________________________ <br /> Type of filter material__- _-__cs �_---_Depth of filter material _-1-9---------Total length---- 043--------------------_...... <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 /> ❑ Size: Diameter- -- ------------- ----- - --------Depth---•--------------------------------------------.-Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well_----------_---_--------------------------------Distance from nearest building------------.--------_-----------.-------. <br /> ❑ Distance to nearest lot line ------------------------------ ------------•-------------•-----•------•------------------ ----------------- ----------------------------- <br /> Remodelingand/or repairing (describe):----------------------- -------------------------------------------------- ---------------------------------------------------------------------------- <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 rulesa d regulations of the San Joaquin Local Health District. <br /> (Signed) / - - - - Fer(Signed) Contractor <br /> By:------------------------------------------ - -- ----------------- ------------------------- (Title) - - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> Fq R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ - - ------ DATE O__- <br /> REVIEWEDBY----------------------------------- ---------- -- ------------ - ------------------------------------------- DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------- ------ - --------- ----------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:------- - -----------------W--- ---------- ------------------------------------ -------------------------------------------------------- <br /> -----W...... <br /> ------------------------------------•--------------------------- ------ ----- ------------------------------------------- <br /> ------------------------------------ •-. ---•------------- ----------------------- ---------------------------------------------------------------------------------------------------------------------- <br /> ----------­-­- ------------------- ------ <br /> I-----, e "-cj �� <br /> FINAL INSPECTION Date.......------------------ <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi California Manteca,California Tracy,California <br /> E.H.9 2M 1.67 Vanguard Press <br />