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FOR OFFICE USE: / -------------------------------------- ------ -- aAP-L�ICATION FOR SANITATION�RMIT Permit No- ----�------------p/----S--- ------------------------------- ------ --------------_-----__ (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issue ------------------ Application is hereby tirade to the San Joaquin Local Health District for a permit to construct and install tork are" .described This application is made in compliance with County Ordinance No. 549, AD JOB ADDRESS AND LOCATION- i.-I. y/ ` ,rL i . r ------•---------• Phone_,4*o...:L' Owners Na _ - --...---- --------------------• - ----i, Address--- �}t � --- �.l _ - "/ ! ----------- - �------ - -•- --��-- - - Phone ----------------------------------- Contractor's ----------------- • Contractor's Name---- f • - - - -------- ----------------- - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other a . , E Number of living units: __----- Number of bedrooms -------- Number of baths ________ Lot size ----------------------____________________--------__________ Water Supply: Public system ❑ Community system ❑ Privatej, Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam'K Clay Loam L3 Clay ❑ Adobe[:] Hardpan C] Previous Application Made: (if yes,date____________________) No New Construction: Yes X No ❑ FHA/VA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,public sewer.is available within 200 feet.)' �Q - Material-- - � Septic Tank: Distance from nearest welL��'__-:Distance-from foundation-__ _ __ � � �----------No. of com artments_____________ Size Lrquid depth-_-__-- ----------------- V --------------- Capacity-�� p �--- --- . e �- -i g Disposal Field: Distance from nearest.well_0!_a..._Distance from-foundation.. _ Distance to nearestlat line.._'_...______. �� s, Number of lines______S__C_-�----------Length of eac h line_3._Y_7, '___ �I1-Width,of trench_- ,`',----r- !' Total' length----- Q:�: ------ ----- Type of filter material____.-� ;/s�,-=Depth of filters mate �_ ___., , ;__ . tr Seepage Pit: Distance to nearest well-'---._____ .__Distance from foundhfion-J---------------Di3�ance to nearest lot ine__'__.___-_._____ Number of pits----------------------Lining material_-..- `- _- ----Size: Diameter__ .-------- -------Depth_ '� ''t .---•-------- ❑ .. _- ti Cesspool: Distance from nearest well____---____—,'Distance-from'�f undation-------------t. -Lining material__-----_____._--___._._________-_____ � ❑ Size: Diameter---------------------------------- p ------ q gals. ---De Depth -- -------------- ----Li wd CapacrtY---------••---------- Privy: Distance from nearest well--___._._--____._--_______________________ __Distance fromnearest buildin --- -•------- ❑ _ t Distance to nearest lot line-- ------------------------------ ---------------------------------------------------------------------- -------------------------------------- --------------- --------------------•---------------- Remodeling and/or repairing (describe)----------------------------------------------------------------- --------- ----1.-----------•----------------- ---------- --- -- s-- �-•----------------------------------- --------------------------------------------------------------•-----------------------------------------------------------------------------------------I------ ----•--------•-----------•---•--------•�---------------•-----•------t------------------------------------- ------- - ----------- - ----- -----•--- --- -------•-------------------------••----------------------•---------- -----------------------•-----------------------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done;in-accordance„with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. I (Signed)----._ - 1 ------------- -------------- ----------------------•------ ------------- - -------- ------_____._(Owner and/or Contractor) --------- ------Oka - - -- --------------------------------------------------------(Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- < -------- DATE-- 3 b ----------------------- -- - -- ------------------------ REVIEWED BY--------- DATA BUILDING PERMIT ISSUED----------------------- -------------------------------------------- --------------- DATE------------------------------------------------------------- - Alterations and/ r recommendations-------------- ----- ------------/--------------I---------- --------------- ------ - ----- _ --------._ ------- --- -- -- --�1`-6 1 FINAL INSPECTION BY` Date---- c _- .� -------------------- C ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stocktonr California Lodi,California Manteca,California Tracy,California E6.9 REVIBED a-59 F.P.CO.ZM 5-b0