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FOR OFFICE USE: / <br /> ---- - Permit No. l ..•�~ <br /> APPLICATION FOR'SAMTATION PERMIT <br /> (Complete in Duplicate) <br /> Date Issued ----- <br /> ------------ -------- <br /> _.__------------____._---._-.___.___ This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Healfh 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 /> 'Z D o 3 3 i►3:_ ,,;� ---------------�` -------- <br /> JOB ADDRESS AND LOCATION_______ Jr <br /> -----�-------- <br /> Owner's Name....-------�.�x�-- --------------•--------------------- ------- <br /> --------------- <br /> ----- Phone <br /> ,may�c - - ---------- -------------- <br /> --------------- <br /> Address . ....---- ......... <br /> Contractor's Name.. ------------------------------------.. Phone............--------- ----------- <br /> Installation will serve: Residence [� Apartment House ❑ 'Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ._'___. Number of bedrooms __-3--. Number of baths _1 , Lot size .... --------------------------------- <br /> Water <br /> _._______...__.____.____._Water Supply: Public system ❑ Community system ❑ Private M Depth To Water Table LP ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,pf Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> I <br /> Previous Application Made: (if yes,date--- --------------) No k New Construction: Yes P5 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 Tank: Distance from nearest well_.:-fir- _ ---Distance/frr-orT),f undation---Z b- Mat�errial-. --•------- 1 <br /> No. of compartments----�------------ Size_ --•-•--- '' Liquid depth-------- ------------Capacity._Z X_�__..... y� <br /> r �v� !.'__._.... C <br /> Disposal Field: Distance from nearest well_S_-!___-___Distance from foundation...............•____Distance to nearest lot line____.. 0 <br /> Number of lines...----1____________--------- ---Lengtk,of,each line..__ �_�_:_.--------- Width of trench--- <br /> JS <br /> rench._. - -•--------...------..._._ � <br /> Type of filter materia� U�'lDepth of filter material_...� .y-----__-Total length_____IG a___--------_____________ <br /> Seepage Pit: Distance to nearest well"":"-----------------Distance from foundation.................__.Distance to nearest lot line-------------- <br /> Number of <br /> ___-______...Number'of pits--------------- ------Lining material--___------- ---------Size: Diameter-------- -------------Depth.----------------•---..._...----- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---.___________-.Lining material_____________________________________ <br /> ❑ �SEze: Diameter--------------------------------------Depth------------------------------- ---Liquid Capacity -----------gals. <br /> Privy: Distance from nearest well--- --------------------------------- -------Distance from nearest building___.__..._._______---________-._-________. <br /> ❑ Distance to nearest lot line-------------•--------------------------- -------•-•------...------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)-----------------------------•---- -------------------------------------------------------------__---W---------------_W---W.................W.... - <br /> -------•-- -------------- <br /> -----•----•----------------------- ------ -----------------_------••--- ----•-----•-----------------------------------........---•---------------•---------------- <br /> ` <br /> 1 he �- <br /> eby certify that I hav ar this application and that the work will be done in accordance with San Joaquin County > <br /> ordine(nces, Stat lg , and u e an egulations of the San Joaquin Local Health District. A� <br /> __....__(Owner and/or Contractor) E_ <br /> � <br /> ByZ------------------------------------------------------------------­-------- ------------------------------------------------(Title)------------ ------------------------------- - -------- Oral <br /> (P t Ian, 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----- 7�02— <br /> REVIEWEDBY----------------------- ----------------_---------------------------_-------------------------------- ------ DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED------------__------------------------ - ----------------M_ DATE...--------------------------------------------------------- <br /> AFterationsand/or recommend'ations----------------------------------------------------------------- -----------....-------------------------------------------------------------------------------- <br /> ---------------- <br /> ---------•----------•-----------••--------------•--------------------- ------- ------------------------------------•---------------------------------------------------------------------------------- <br /> ---------------------- <br /> ---------------------------- --- -----------------------------------•------------------------------------------------ ------- ---------------- <br /> FINAL INSPECTION <br /> I -----• Date----.1.a'z-_r .',;'..2----- ----------------_­------------- <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 9-59 2M 5.62 ATLAS 1:.= <br />