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FOR <br /> �,OFFICE USE: <br /> ---------� AT..4.66t------------- --- <br /> )f � 17 APPLICATION POR SANITATION PERMIT Permit No. <br /> --- ---V4 <br /> -----------------1--` -------------------------------- (Complete in Duplicate) <br /> --------------------------------------------------- <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 /> /�/` o 7 � <br /> JOB ADDRESS AND LOCATION..-. ----/-------------------"---------------•------------------------------ <br /> Name------ _ ----- <br /> --- F --' .F,y=-•--------------- Phone <br /> 6--------------------------------- <br /> Owner's <br /> Address----------------- ` ------ --=--•�--------------------------------•--- -------------- <br /> .' -----------------•• • --- ---------------------------------------------••-•----- ------•--...---- <br /> Contractor's Name------ ------ ­1­1­----------------- - "-------------------------------------•-----------------------------._. Phone----------------------------------- <br /> Installation will serve: Residence Apartment Hoiise ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .d <br /> Number of living units: ___/___ Number of bedrooms-.3___ Number of baths ----/.- Lot size .- ____.__._-- <br /> ' <br /> Water Supply: Public system �ommunity sysfem El Private F-1Depthto Water Table _�7ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy,Loam ❑ Clay Loam lay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: - (If yes,date3-y .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 T k: Distance from nearest wel ---�D tsi ancerfrom foundation__ �� -f <br /> _f_C��____.Mat rial -_--!__ - <br /> I <br /> No. of compartments_..___.._ Size__ X__ __ � iquid depth-------- _______________Capacity... �1— � <br /> 'f <br /> 7•t 0 <br /> Disposal Meld: Distance from nearest well...._ ts#ance from foundation__-`__.---__.__.Distance. to nearest lot line______f`"___. <br /> Number of lines----------------- Length of each line-------- ______..Width of french.----.2_1_-________._____.____ <br /> Type of filter material--- -_/?_`111'�epth of filter material-------j_rg__`!_.Total length-----.__.___��'td�______________ i <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______.______.__ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------.------------ Depth--------------------------------. 1- I <br /> --T <br /> Cesspool: Distance from nearest well_--------- _____Distance-from•foundation____________________Lining material___.____________.._.__.__________--__ <br /> Size: Diameter----- -------------s---------------De th----------------4----- ------------------------ Liquid Capacity ----gals. <br /> i <br /> Privy: Distance from nearest well=`_..______.:---------^__.___---_-------!_..Distance from nearest building_________________ ___________ ________ <br /> ❑ Distance to nearest lotli ne-- - ------=- --------+ - - - - <br /> ----------------- --------- ------------ --------------------- ----------------•----------------------- G I <br /> t <br /> Remodeling and/or repairin (descr e__ _ -- - - ------------------ ------------------ <br /> ---- t.---/-- f <br /> ,->� 1- �-----------------------.. �- ------ ----- --------- --- <br /> ` `- -------------------- <br /> ---------- <br /> `' ' --------------------------------------- ------ <br /> -7-- ---- ---------'------------------- -�------� ----------------------------------------------------------------------------------- <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) f------------------------------ - -------- ------- __.(Owner and/or Contractor) <br /> --------___t) : <br /> By:----------------------- <br /> _---------------------`--------------------------------------- --- ----------------------------------------(Title)---------- --------- --------------------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). p <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-==---- ------ " —----------------------- DATE------3 ----- ---- '------------------ <br /> REVIEWEDBY------------------------- ----- ------- --------------------------------------- ---------------------------------- DATE---------------------------------------- - - -- ---- <br /> BUILDINGPERMIT ISSUED------------------ ---------------------------- "`- DATE-------------------------------- --.----------------------- <br /> Alterations and/or recomme datihns:______. _. .__4-- --��-��----...__(--- ----!`------------ r� <br /> fc <br /> ------ ------------------------ <br /> ` lam* — --- Date-- / �� --------------------- <br /> FINAL INSPECTION BY:.. f .-.__._ _ �-------��--- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Nazenon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodir California Manteca,California Tracy,California <br /> F.F'.o o. 4 <br />