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R OFFICE USE: <br />-------------------------------------------------------- <br /> APPLICATION FOR ANATION PERMIT Permit No <br /> (Complete in Duplicate) ``' <br /> Date Issued <br /> --------------------- This Permit Ex ires 1 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. i <br /> �� •------------.....-•-------------......... <br /> JOB ADDRESS AND LOCATION._.- - -.-._._ ..-Wil•;•--__._-__--•;.-------------------------------------------------- <br /> Owners Name....-_-._ ._ - �7- <br /> -' � - '` 'J' - ------ Phone...`. . <br /> ------------------------------- <br /> Address......... • -�. <br /> -'-+- <br /> h <br /> Contractor's ( -•--- <br /> Installation will serve: Residence ❑ Apartment Hous ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _7--. Number of bedrooms _.Z--Number of-baths-.-L.. Lot size ------------........ <br /> Water Supply: Public system ❑ Community system ❑ Private Q-15epth To Water Tabie i!�??. 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 [G.—New Construction: Yes V;---No ❑ FHA/VA: Yes ❑ No ❑ i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ILA <br /> Septic Tank: Distance from nearest well---,�..--P..Distance from f�oundatjon__/_0----------Material----- -------------------------------------------- <br /> P No. of compartments--------.Z _. ----Size .X_- _-j .Liquid de th---.--- --- Ca aci <br /> Disposal Field: Distance from nearest well---171U----Distance from foundation..-,.-----..Distance to nearest lot line_-_ -....• p� <br /> Number of lines------------------7---------------Length of each line..--____. - ---Width of trench-------Z-�------ <br /> --_--.._---_ 11} <br /> .... � . J <br /> Type of filter matenal:_�.�'1.`--��.__-Depth of filter material-------- .�-----..Total length.........��=-f��__7, <br /> Seepage Pit: Distance to nearest well-_-------------------Distance from foundation....................Distance to nearest lot line....------------- <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth-----------------------........... <br /> Cesspool: Distance from nearest well_-_-------------Distance from foundation---.---------------.Lining.material----------_--------------- <br /> 1­1 <br /> ...--.--- ..-._.-__-..-❑ Size: 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):------------- st'�"7 ] �`� ." �-•-----��•...I---��-----��--�- <br /> ----- ---------------------------------•-------••--------------------••---------------------•---•-----------------------•--•---------------- <br /> -------•----------------------------------------•----•-----•----- --------------•-----------------•---------------------------------------------------------------------------•---------•-----••--------....-------- <br /> 1 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, d rut nd ulations of the San Joaquin Local Health District. <br /> ----Owner and/or Contractor I <br /> (Signed} ` :. ( / I <br /> --- --- - <br /> Title <br /> By:--------- -------------_-------_ ------------------------------------------------------------------- � ) <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 /> APPLICATION ACCEPTED BY--------- --- - -- <br /> ---------- ---- DATE----------j_ -`/----�-'"i- ~---------- <br /> REVIEWED BY---------------------------------------------------------- /__------------ DATE <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------•------------------------•------------------- DATE--------------------------------------------------------- •- <br /> Alterationsand/or recommendations:.------ •------------------------------- -----------------------------------------•------•--•-••----------------............._....--- •----...........---• <br /> -------------- - ------------•---- ' ---- --- -------------------- --------•-••----- ---------------------------------------- <br /> /' �� <br /> FINAL INSPECTION BY - --- ---------- -- -- Date .............. <br /> S N JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 3 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California / Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 0-59 2M 5-62 ATLAS <br />