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R OFFICE USE: <br /> FOR.- ,�°-�----- - APPLICATION FOR �ANI7ATf4N PERM17 �l?ermit'No. f� <br /> `� -- <br /> (Complete in Duplicate) Date Issued -� - --- <br /> > This Permit Expires 1 Year From Date Issued <br /> ----------- <br /> Application is hereby made to the Sari,Joauin_Local Health District for a permit to construct and install the work herein descn e . <br /> This application is made in compliance <br /> with County Ordinance No. 549. i <br /> JOB ADDRESS AND LOCATION_--- JO. �-------------- - -- <br /> - ...=-: ---------------- -------- <br /> l _ R <br /> Owner's Name _ "" _= ~ �` :- Phone._11��u- <br /> k ------------ ----••-------- <br /> Address---- - - ^�q ...............------------------ ------------•••--------------------------------------- / <br /> e„LP Luat1. .... P� '-------------- ----- ---- ... Phone.lVaV27-9��.7_----- <br /> Contractor's Nam - <br /> Installatiori will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court <]' _NSotel ❑ Other ❑ <br /> f �' _ _________ ____ <br /> Number of living units: __1----- Number of bedrooms t - to Depth to Water Table s4 <br /> k ,�----- Number Number of baths _�.___ tot size` <br /> i tlw_ ft <br /> Water Supply: Public system (�J: Community system ❑ � Private ❑ p r <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 ❑ 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 /> I Septic Tank: Distance from nearest well- '--�__-----Distance from foundation...-_�--`----._.Material ---- ------------------- <br /> Material <br /> of compartments-------- --------___Size------11;4-�- -----------Liquid depth__��J.:.'. -.------Capacity-----�Ad0----- <br /> Disposal Field: 'I . Distance.ffrom nearest well------ ---------Distance from foundation__. _`.....-.Distance to nearest lotline__------- <br /> Number of lines.-------- ------------ -- Length of each line---------7-` -------Width of trench------- y~---------------- <br /> Type of filter material-- -���-------Depth of filter material___.-- 49_"___-Total length------ SSG_'----------------------- <br /> Seepage Pit: Distance to nearest well..._x---------------Distance from foundation---r�0----------.Distance to nearest lot line--._-----_ <br /> Number of pits -- ------ -- ----Lining material-----l�. Size: Diameter.--- '---------Depth------?2'5----------------- <br /> Cesspool: Distance from nearest well ----------------Distance from foundation_.--------------_ _.Lining material-.-_._-__--_.--....__--..-_-_._---.. <br /> 1 ❑ Size: Diameter- -- --------- ----- ------ ---------Depth--------- ------- -------Liquid Capacity------------- -------------gals. <br /> Privy: <br /> Distance from nearest well------------- --- .. Distance from nearest building------ ------------------------------ <br /> ❑ Distance to nearest lot line --------------- --------- - -``---yy----- -----------------------f-�--•---------------------- -------------- - -------- ----- ----------:-- <br /> i Remodelin and/or repairing (des ;r3"` � r `� ---------------- <br /> ---------------------------------------------------------------------------------- -------------7----•------------------ <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 lawst and rules and regulations of the San Joaquin Local Health District. <br /> Y. . <br /> S072Q.� ---------.-f ----------•---------------------- ------.(Owner and/or Contractor) <br /> (Signed)__�P. ------ ', -. <br /> -----------------(Title)_..> t. ---- ----------- ............... <br /> (Plot plan, showing size of lot, location of system in relation to ./ells, buildings, etc., can be placed on reverse side). <br /> FOR DEP- RTMENT USE-ONLY <br /> APPLICATION ACCEPTED BY' - DATE----��------ ------ ---- ------------------------ <br /> -------- --------- <br /> REVIEWEDBY------------------------- -------------- -------------------------------- -1... DATE--------------------•---- ---------------------------------- <br /> iBUILDING PERMIT ISSUED------------------------------------------------------------ -------------- -- -- ---------------- DATE--------- ---------------- ------------------------------- <br /> Alterations and/or recommendations: -----------.. <br /> ----------------- --------- ---- ---- <br /> 4+« _. _..-_...._..._-------.,----------------------------'"--• <br /> .............................."_.__....._....._.__.-------_._-------------_--- -_ _ <br /> Y _ } � r � e <br /> -fie ,,,,..,, pp .Z —1 — <br /> FINAL INSPECTION BY:..- -- ---- _ _"L Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Slockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />