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FOR OFFICE USE: � 14 00Ai <br /> -----------------I--------------------------------------- �71 <br /> APPLA110N FOR SA(NITATION PERMITPermit No. <br /> ----------------------------------- -------------- (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. 549. <br /> JOB ADDRESS LOCATION ................................. -------------- <br /> --­------------------- <br /> Qwner s 140FTIV `7e..... /Phone--------------------------- <br /> ? ---------/' <br /> I .." . -- ------------ Z............................................... <br /> ----------- -------------- .... .....- <br /> 614�dres ------------- <br /> s--------------------------------- ... ------ ............ <br /> .................... <br /> Contractor's Name......... ------------ Phone................................... <br /> ---_ ---------------------------------------------------------------------------------------------------------------- <br /> Installation will serve: Resiclence'V_ Apartment House E] Commercial E] Trailer Court C] Mot I C] Other 0 <br /> T <br /> Number of living units: J..... Number of bedrooms ------- Number of baths Z <br /> ----------------------- <br /> --- Lot size <br /> Water Supply: Public system El Community system O(Private [] Depth to Wafer Table <br /> Character of soil to a depth of 3 feet: Sand E] Gravel []' Sandy Loam El Clay Loam jk, Clay E] Adobe E] Hardpan <br /> Previous Application Made: (if yes,clate--------------------) No �_, New Construction Yes OICNo E] FHA/VA: Yes r-1 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well _.:, 4 foundation_ t ---------------_____._.,.,,;._t,__. <br /> --- ---Dist n.- <br /> _..___.___Liquid de h---/. �-----------Capacityl­�-'-­ _ <br /> No. of compartments---ef -------------Size...:X�_1--.= . <br /> ............ <br /> Dis I Field: Distance from nearest well---1_1'­__fAbistance from fo n Jafion <br /> u :!t........ Distance to nearest lot jine <br /> Number of lines-----4:------ ---- Length of each line--- //.......Width of trent <br /> PW ----- __''.--___--___-Total <br /> Type of filter material.--�.�-1---t--Z,-�iADepth of filter material-__ length---�1.6�_� <br /> Seepage Pit: Distance to nearest well---------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> El Number of pits______________________Lining material-----------------------Size: Diameter____-_.-_----...___.__.Depth--------------------------------- <br /> Cesspool: Distance from nearest well---__._--_-._-_Distance from foundation------------------.1ining material-_____..-____--___-................. <br /> El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--____.-__-_..-----_____-__-___-..---__._. <br /> ❑ <br /> uilding------------------------------------------ <br /> ElDistance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------............................ <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, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed).... I ------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:..................... a------ <br /> ----------------------------------------------------------------------------------(rifle)------------------------------------------------- ------------ <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 /> APPLICATIONACCEPTED BY------------------------------------------------------ ---------------------------------......... DATE-_------------------------------------------------------- <br /> REVIEWEDBY---------------------------------------------- --------- ----------------------- --------------------------------- DATE--------------------------------_---------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:------------------------------------- -----------.....................................................---------............................................. <br /> ---------------------------------------------------------------------------- -------------------------------------------------------------------------....................................................................... <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----­-­------- ------------------ ---------------------- ...... ------------------------------------------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:--- Date-------------- --- - --------------- ---------- -------------------- <br /> ---------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Eli 9 REVISED S-59 3M 3`63 F.F.00. <br />