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FOR OFFICE USE: /� G <br /> ------------------------------------------------------- <br /> -- <br /> --------------- - - -- ---------------_ -------- ---------------- -------------------- -APPLICATION FOR SAIIITATtON PERMIT Permit No. - <br /> r <br /> -------------------------------------------------------- <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 scribed. <br /> This application is.made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION___ __ j Zl/� -w ��r_ � <br /> oe acv <br /> --- <br /> Owner's Name---,:-_- f_ <br /> ------------••---•------------------ -------------- ------------------------------ Phone------------------------------------ <br /> Address..........'��' /. + 0 <br /> cr-C. <br /> ---- - ------ <br /> Contractor's Name--_ <br /> ame - ----•-•---- ------------------------- -----------------------------------------•----•-------------- Phone <br /> Installation will serve: .Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -J____Nurfiber of bedrooms 3____ Number of baths An--- 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 ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date___________ _____I No New Construction: Yes 0"'No ❑ FHA/VA: Yes ❑ No Et—__ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br />+ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> SepticTank: Distance from nearest welL�O_f.___Distance from foundation_.-_la__'__-___.Material___.-- <br /> No- of compart€ents____az________________Size___�'31f 3Cs "�- Liquid depth--------- -_`__-----------Capacity--/2-4;wrikc. <br /> Disposal Field: Distance from nearest well. 7-0'-___._Distance from foundation---/1?_f_______-Distance to nearest lot line---�5_:_r__ - (/l <br /> Number of lines---- -------------------------Length of each linewa---:-,oe-Q----------- Width of trench------ - - -----------••- <br /> r ... ` <br /> Type of filter material......_�''itc>!C_Depth of filter material__/,�-_-'_._.______Total length---.2,_-y�'________________________�= <br /> Seepage Pit: Distance to nearest well_____ ____________Distance from foundation------------..___-_.Distance to nearest lot line--_____-_________ <br /> ❑ Number of pits-- ------------------Lining material-----------------------Size; Diameter-----------------------Depih--------------------------------- , <br /> Cesspool: Distance from nearest well--------------_Distance from foundation--------------------Lining material--- -----.-------------- <br /> - <br /> Ih <br /> ❑ Size: Diameter----------------------- --------Depth-------- - -----------------------------------------Liquid Capacity---------------------------------- <br /> ------gals. <br /> Privy: Distance from nearest well_________________________________________________Distance from nearest building <br /> --- <br /> ❑ Distance to nearest lot line ------------------ <br /> ------------- ---------- ----� <br /> f <br /> Remodeling and/or repairing (describe):___--- ------------------------ . <br /> --------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- 6 <br /> t <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, State laws, arules and eg lations of the San Joaquin Local Health District. <br /> (Si ned <br /> 9 )-------- --------Of------- `--------------------------- ----------------------------- --------------------------------------------------------- -- -(Owner and/or 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 /> FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY_._ --------- --- ----------------- -------- -------------------------------------------- DATE- <br /> REVIEWED BY I <br /> --------------------------------------- <br /> ----------------------------- --------------------------- DATE-- 1 <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------------------- DATE _ -------------- <br /> Alterations and/or recommendations------------------- --- ------------------------------••-_.------------------------------ <br /> ------------------------------ <br /> - ----------------- --------••------ • ---------------------------- -----------------------------I-------------------------•------------------------------------------------------------------•--- <br /> FINAL INSPECTION BY:...... -� Date-._-__.�2_=Z __-_- <br /> ---------------------------------- <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha:ellon Ave. `` 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California 4 Lodi,California Manteca,Callfornia <br /> Tracy,California <br /> F,RCC. <br /> 1_ <br />