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FOR PFFICE USE: <br /> ..---....... �� ... E. _._...._. . <br /> ........................ ................... <br /> APPLICATION FOR SANJTATION PERMIT Permit No. _�f D3a�- <br /> ........................................................ (Complete in Duplicate) <br /> __�. <br /> ................. ......_ .. ....... This Permit Expires 1 Year From Date Issued 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 Cou ty Ordinance No. 549. <br /> JOB ADDRESS AND `LOC )ON--- <br /> -- ------- -- .................... ... <br /> ............................................................... <br /> ..... <br /> Owner's Name-._ ..�. - _._...__ ......................... - one <br /> Address --- - <br /> ... <br /> Contractor's Name-- --- -- --- - ----- ----•-----..-------.-.-..-•-----------------•----••---- ---------------- Phone. .... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ra�iiller Court ❑ Motel ❑ Other ❑ <br /> ��' '. Number of baths Z / <br /> Number of living units: .---.... Number of bedrooms ..- _.._ Lot size y/._.14A/.`G.................................. <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 ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [?"Hardpan <br /> Previous Application Made: (If yes,date.. ........) No �New Construction: Yes F?"—No FHA/VA: Yes ❑ No F <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> No. of compartments...-- --------........._Size.---------- - Liquid depth_-_ -----•----. ---•.-:•--Ca cit - <br /> Sept ❑k: , Distance from nearest well______________ _Distance from foundation_.._.____ ......... <br /> ----•-••-•- --- Material------------- pout <br /> Disposal Field: Distance from nearest well..Z .-0... Distance from foundation.-.__P.,e*7...-...Distance to nearest lot line. <br /> Number of lines._._.._l-_....!_ - ._.... Length of each line.. +/.---_-,�--.....Width of trench_..__--.. .__-. -__...._.. <br /> Depth of filter material._ .. pp... Total len th-..-: -___ .. <br /> Type of filter material_/_ - p w Ir 9 <br /> Seepage Pit: Distance to nearest well- -Distance frop fo ndation---L?.40-........Distan� to nearest lot line ... -.--.. <br /> Number of pits_....___.......Lining material_ _..Size: Diameter........._.__.._- Depth r,1`�..i X- <br /> I Cesspool: Distance from nearest well.................Distance from foundation.........-----------Lining material....-__-.-..----_-•_.-. ---.-.--..- <br /> El Size: Diameter ......... - .............Depth.......... .........................................Liquid Capacity....------•-...._._._.. 981: <br /> Privy: Distance from nearest well.............................._._-.-_-.-.- _-..Distance from nearest building...................--.._-.--..._..--..-- <br /> ❑ Dis}ance to nearest lot line................. ---------------- ------ _----•--••-•-. ... <br /> . - <br /> �� --------- ----- ----- <br /> Remodeling <br /> and/or repairing (doscribe):..---.-•--_---•���'G_ �l <br /> . <br /> .................. ..••------ <br /> -_----- -- ---- <br /> ---4' ..................------------------------------------------------- ------------ <br /> -----•••.... ......................................•-•..:-----....--------------------------------------­-----­---- ----------..................................... -----....---•-•-••--------••--......•----.......... -... .. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin Count <br /> ordinances, State laws, and rules a regulations of t e San Joaquin Local Health District. <br /> (Signed)_ _............ . .. ._.(�p Contracto <br /> _..... _ _ <br /> R ----(Title) <br /> f (Plot plan, showing size of lot, location of system i r tion to wells, buildings, etc., can be placed on reverse side). T <br /> FOR DEPARTMENT USE ONLY <br /> n <br /> APPLICATION ACCEPTED BY--------- ­ .......•. . .. ..... ' r1------•--- DATE .� ./ - �' �� <br /> REVIEWEDBY._ -------------- •--•-•------------.--•-----• DATE---......------ -----•---------••----------•-.----------- <br /> BUILDINGPERMIT ISSUED.................................. - ..................... DATE................ -----------.........------•--------- <br /> -------- <br /> Alterations and/or recommendations:...._..::._ .. ._-(__ ...........:......./-� times`= <br /> .......---•-•---•.................•--....-•--......•--- ..I.....................-----......•-•-----......_... ................................. <br /> ........................... .................• ...........----••----....................................----••--•........................................ <br /> ............................. <br /> FINAL INSPECTION BY:. --._... .. <br /> �jf' - - - ............ ........ .........._ Date-_...-- <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 /> r.r�.cu <br />