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FOR OFFICE USE: <br />--------------------------------------------------------- <br /> APPLICATION FOR SAN-iTATION PERMIT Permit No. <br />--------------------------------------------------------- <br /> �. (Complete in Duplicate) Date Issued <br />------------------- --------- This Permit Expires 1 Year From Date Issued f e­-�_2-20—t, <br /> Application is hereby made to the Sane 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 Ng, 549p/;�040,9&p RO, <br /> JOB ADDRESS AND LOCATION 5- =SOX__�59_ -- -... . -- /N ------ -- �'°l, d-- .>�-c Q, <br /> Owner's Name------ / ------, 1 � .5------------------•-----------------::.----------------------=------- ------------- Phone------------- ------•-••------- <br /> Address----------------�T= .........Z? Z-I ------------------ .----T -----lbFL4 ---------ele,p---------------------.. -..------------ <br /> Contractor's Name-----'-- ....... --•------------------•---F----------= ----------------------------- Phone.............------------_------- <br /> Installation will serve: 'Residence [ hApartment House'.[-] lCominercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ <br /> Number of living units:'1---Number of bedrooms -&A--.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 ❑ Gravel a❑` Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeig Hardpan ❑ <br /> Previous Application Made: (If yes,date__�'-a-------------1 No X New'Construction: .Yes M No ❑ FHA/VA: Yes ❑ NoA <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:j <br /> (No septic tank or cesspool permitted.if public sewer--is available within 200 feet.) - <br /> Septic Tank: Distance from,nearest well---- .......Distance from foundafion____,fP_--___�, <br /> Mater�aL:_ t - Ma 7- <br /> '--- ------------- <br /> No. of compartments-..__- ------------Size- XIX_ ------Liquid depth_.__'....'....__..._-xCapacity --- <br /> -4 i j -Z1 <br /> Disposal Field: Distance from 'nearest)well._ j`a.(---'Distance from foundation_--./Q__'.!---.Distance to nearest lot line----4.�1_..... <br /> .. <br /> Number of lines"M_e__-__Z-..----"'____.__-Length of each line--------���.� ---.Width of trench---------- .--._.__._----.. r� <br /> Type of filter material---s� �Depth.,ofjilter_material__.--/AF_1 <br /> _, Total.lengfh_�7Y-1 '---____--- <br /> Seepage Pit: Distance to nearest well_.-°---- ---_----_-__Distance from foundation--------------------Distance to nearest lot line----------------- <br /> [] Number of pits- r:}-----Cining material-----------------------Size: Diameter-----------------------Depfn---.----------------------------- d <br /> e F <br /> Cesspool: Distance from nearest well-----------------Distance from 'foundation------------------..Lining material----___------------_---.-_-_---__-_ <br /> ❑ Size: Diameter-----#=-----------------'-----------Depth-----------------=--- -------------- --------------Liquid Capacity- --------------------------gals. � <br /> E <br /> Privy !' '7Dist6nce from nearest well----- -- ---------------------------------------Distance from.nearest'building---.-.-.-----------------_----_---_____. <br /> ❑ Distance to nearest lot line--------------------------------------------- ------------------------------------------------=--- ------ -------- ----------------- - <br /> Remodeling and/or repairing (describe)=------ ------------------------------- <br /> - <br /> 1 I <br /> I . <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) f -: (Owper and/or Contractor) <br /> By:..... ......�. - - ------Y--- --------------------------------------------------(Title)--------- --- - ---------------- <br /> (Plot plan, showing size of lot, locat101 of yStem in relation to wells, buildings, enc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--- ------4--------------------------------------- -------------------------------'------------- DATE---------------------- ----- - ------ <br /> REVIEWEDBY--------------------------------------I...... ----------------------------------------------------'---------- ------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED--..--•-------- €------------------------- ---------------------=------------=------ ----------- DATE--- ---------------------------------------------------------- <br /> Alterations and/or recommendations:------ --------------=------------- ----- 'r-------•---------------� ----••------------------------------------- --- <br /> ---------------------------- ---- ------ - ------------ , <br /> ------- ------------------•--------------------------------------------- <br /> �� ------ ---------------- - -------------------------- ------- <br /> 1 _--------/r� 7- --- ------------------ ------ - --------------------------------------------- - <br /> I t <br /> f_ - Date._ �f ,G, _ E� <br /> j <br /> FINAL WSPECTION BY:. ---- -- � ------------- ------ - -- ------ = ------- <br /> . 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 6S 9 REV35CO B-59 3M 3-'63 F.P.0 . ,t <br />