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FOR 7�1 0 CE USE: ATION PERMIT Permit No. <br /> ------------- <br /> -- <br /> - -------------------------------------------------- APPLICATION FOR StNIT .......... --- <br /> ------------------- -- ------ --- ----- ----------------- (Complete in Duplicate) <br /> Date Issued ? y -----65- <br /> ----- -------- --------- ------------------ This Permit Expires I Year From Date Issued <br /> Application kis 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 w�iifh�WCounty Ordinance No, 549. <br /> ---------- <br /> JOB ADDRESS AND LOCATION_ - - - - --- ------------ <br /> -------------- ------- - <br /> - - <br /> Name---------e1_r!fE_a4.-�---------- - ---- -- --- -- -------------------- -----.__,Phone-.....------ <br /> 'Addr6sS.......... ---------- -------- ----- - -------------------------------------------------------------------------------------------1 <br /> ------ - -- -------- --------- <br /> Contractor's Name------------ --------- 0 <br /> ;e - ----------------------------------------------------------- Phone.. <br /> Installation will serve: Residence P-'-Apartment House ❑ Commercial El Trailer Court El Motel El Other El <br /> Number of living units: J---- Number of bedrooms Number of baths _sr.,__ Lot size ----- -------------------------- <br /> Water Supply: Public system [] Comm-unity system �Private E] Depth to Water Table -----_._.ft'..x <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [] Clay Loam 0 Clay [] Adobe a Hardpan ❑ <br /> Previous Application Made: (If yes,date-._- -------------) No Zj— New Construction: Yes HN No El FHA/VA Yes No E:1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic fankior cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance. from nearest well--fito-------Distance from f9undation----ZA-1-------Maferi'al----4 ------ <br /> No. of compartments-------2—--------------Size-Alk-YAX-1----Liquid depth__...____ ------------Capacity__JZ.-_0 <br /> I �Pe <br /> Disposal Field: Distance from nearest well-Aled--------Distance from foundation----ZA----------Distance to nearest lot line--r-1!------ <br /> t <br /> ------------ <br /> Nu4er of lines--------------2------------------Length of each line-------- Width of trench.----- - -------------------------- <br /> Type;of filter material------R_�_c_k---Depth of filter material-----I-S!-----------Total length_-_._-_- ----------------------- <br /> $ 1 t - <br /> Seepage Pit: Distance to ne5restiwell___A/©----:-------Distance from foundation___1.4?-----------Distance to nearest lot hne_.6;..:!"------- <br /> Number of pits------4-------------Lining material--__ ....Size: Diameter---d-3.............Depth-----2__.: 7_.---_..___--__ �.. <br /> : 1 <br /> Cesspool: <br /> --------------- <br /> Cesspool- Distance from nearest weli-----------------Distance from fo.unclation....................Lining material-.._____.._.__.______._.._:--__-----. <br /> ---------------------- <br /> Size: Diameter-- ---- ------------------- - -- ----Depth_------------------------------- -------- --------Liquid Capacity- --------------------gals. <br /> once e" es ----- ----- ----- <br /> well- ------ --- <br /> Privy: ante from nearest.well-- ----------------------------------------------Distance from nearest buMing-------------- --------------------------- <br /> _❑ bi,�tance sf lot line------------------------------------------- <br /> -------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (fdesc"iribe):-------------i--------------------------------- <br /> ----------------------------------------------I---------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- <br /> --------------------------------------­---------------------------------------------------------------------------- --------------•----------------------- ------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------2�m�------------------------------------------------------------------------------------------------- - ------ <br /> I hereby certify that I have prepared this application and that the work will'be�one in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations-cif the San Joaquin Local Health District. <br /> (Signed) -r and/or Contractor) <br /> ------------------- ------- ------- ------- ---- ------- -------------------------------------------------------------------(own <br /> By:---------------------------- - --- -------------------------------------------------------------------------------------(Title)_ - ------- ----- - - <br /> (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> op, <br /> APPLICATION ACCEPTED 13Y_...__..__ Aeo <br /> --&------------------------I--------------------------------------------- DATE..... '56 <br /> ---------------------- <br /> REVIEWED BY------------I-------------------------------- ----------------------------------------------------I-------------- ------------ DATE-------------------------- <br /> -------------------------- -- - <br /> BUILDING PERMIT ISSUED------------ ----------- DATE---------------------------------------------------------- <br /> --------/W-- ----------—----------- <br /> Alterations and/or rec�mmendaf ions:------ -----n ------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- ------------- <br /> --------------------------I--------------------------------------- --- ------- - -------------- ------ ------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------- --------------------------------------------------------------------------------- ------------------------------ -------------------------------- <br /> --------- ----------------------------------------------------- -------------------------- ------- -------- --------------------------------------------------------------------------------------------------------- ----- ----- ........ <br /> FINAL INSPECTION <br /> BY'_ Date.------ ------------------------ -------------------- <br /> ---------- -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California ')j Manteca,California Tracy,California <br /> F.P.C13, <br />