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FOR OFFICE USE: <br /> v APPLICATION <br /> APPLICATION FOR SANVATION PERMIT Permit No. <br /> -----------------L--------------- --------- -------------- <br /> ------q-_-_0--------- (Complete in Duplicate) Date Issued <br /> ------------------------------------------------- This Permit Expires I 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., S49. <br /> JOB ADDRESS AND LOCATION--- --- <br /> -4� <br /> ------------- / 45� ----------------------------*------*---------------------------------------- <br /> Owner's Name 141----- --------------------------------------- - -- ---------------------------------------- Phone------------------------------------ <br /> �T- -------- <br /> Address - ---------------------------------------------- ---------------------------------------- <br /> --- --- --------- <br /> ------- -------------------------. Phone----- ----------------------------- <br /> Contractor's Name--- -------- <br /> Installation will serve: Residence [g-Apartment House ❑ Commercial F1 Trailer Court [:] Motel E] Other E] <br /> Number of living units: J----- Number of bedrooms -J-,-- Number of baths t___-_- Lot size ---070-X-4;,-V------------------------------------ <br /> Water Supply: Public system E] Community system 0 Private [B-'-D-epth to Wafer Table -k-oft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam El Clay E] Adobe E—Hardpan 0 <br /> Previous Application Made: (If yes,date--------------------) No [n'--New Construction: Yes Eq--No [-] FHA/VA-. Yes [I No [i J— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer isavailablewithin 200 feet.) <br /> Septic Tank: Distance from nearest well---- 0 <br /> 16- - <br /> -------------Distance from foundation-14! -- <br /> -- ------- Material------------------------------------------------ <br /> No. of compartments--------�2--------------Size- ..---------R-------Liquid depth---` --- ---- ------- <br /> f <br /> Disposal Field: Distance from nearest well- -----Distance from foundation___1'9............Distance to nearest lot line___.___.______.__ <br /> Number of lines-----------i---- --------Length of each line----719--------------------Width of trench--,2,j_'_-------------------.- <br /> Type of filter material�7170-G---(-----------Depth of filter material-/,15--, _---.-_.-Total length--- ----------------- <br /> Seepage Pit: Distance to nearest well---,'616----------Distance from founclafion--4a.............Distance to nearest lot line-..-S_+_- -..._ �1 <br /> [L]� Number <br /> ine-..-S-------- <br /> Number of pits.--.-j---------------Lining material' &.G4------.Size:Size: Diarriefer-3.2-4-----------Depth-------20-------------- <br /> Cesspool: Distance from nearest well-------------- --Distance from foundation------------- -----Lining material----------------- -------------------- <br /> 0 Size: Diameter--------------------------------------Depth------­--------------------- -------------- -------Liquid Capacity--..------------------------gals. <br /> Privy: Distance from nearest well-------------------- Distance from nearest building----- ------------------------------------ <br /> 0 Distance to nearest lot line----------------------- ------------------ - ----------------------- -------------------------------------------------- ------ ------------ <br /> Remodeling and/or repairing (describe)____________________________________________ ------------------------------------------r----------------------------------------------------- <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, and rules and regulations of the San Joaquin Local Health District. <br /> (Si 'ned)------------------------------------------------------------------------ - ------- - - ------- ----------------- --- -- ---------------------------------- ---(Owner and/or Contractor) <br /> 9 F I <br /> By:----------------5(-!C�LMA�-------------------------------------------------------------------------- -------------ffitle)----- --------------- --- - ---------- <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 <br /> APPLICATION ACCEPTED BY----------------- ------------ --------------- DATE------------- 21-le-------------------- <br /> REVIEWEDBY-------------------------------- --------- ---- --- --------------------------------------------------------------- DATE------------ ------------------------- <br /> BUILDING PERMIT ISSUED-------------------------------- - T --------- --- <br /> ------------ DATE------ <br /> ------------ .1--------+---------- <br /> ----------------- <br /> Alterations <br /> ------- -------------------------- <br /> Alterafions and/or recommendations:------------1-1-A -�t <br /> ---------------------------- --- -- ------ ------- ----------------- <br /> ---------fL V- - --t--- --- - <br /> - ---------- -------------- ------- <br /> -----..... . -------------------------------- ---------------------------------------------------------- <br /> ---------------------------------------------------- ----------------------------------------------------------------------------------- -------------------------------------------------------- ------------------------ <br /> ------------------ ------- ------- --- -------------- ------ --- - --------I---------------------------------------------------------------------------------------------------- ------ ------------------------- <br /> ------------------------- -------------I--------------- ........ --------------------------------------------- ---------------- ------------------------------------------- -------------------------------------------------- <br /> 4-FINAL INSPECTION BY:- ---------- ------------- Date.__._. -------------- ------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon 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 />