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FOR OFFICE USE: <br /> -------------------------------------------------------- <br /> ----------------------------- ---. .---_.APPLICATION' FOR- 'S_XNITXTIO W.PERMIT Permit No. I.................. <br /> --------------------------------------------------------- (Complete in Du lica e <br /> —�` .,.,­ <br /> ------------ --------­---------- This Permit Expires I Year From Date Issued Date I sued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct.and-insta erein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AbIO-_t'S�_-ATION <br /> Owner's Name----------- . ... ....... .... e <br /> ... .... ... . ... <br /> ------- ----- ------------------- <br /> 01 <br /> Address----------------- --------- <br /> .. ......... ---------- --------------------- <br /> Contractor's Name---------------------- - - ------------ --- ----- ----- --------- ----------- e---------------------------- Phone. <br /> Installation <br /> hone-Installation will serve: Residence�._A_p2arfimenf House E]4 Commercial E] Trailer Court L] Motel L] Other <br /> .Number.of living units: -- Number of bedrooms -- <br /> ., Number baths --/ Lot size ----w- -- <br /> -- ------- --------------------- ---- ------- <br /> -/_ <br /> Water Supply: Public system E] Co-m--marl'ity-systern.[] f;vate [11 Depth Water Table--:-.----'- ff. <br /> Character of soil to a depth of 3 fed: ' Sand E] GravelE]..�-Sancly Loam Depth <br /> Loam [] Clay Ej Adobe[D Hardpan El <br /> Previous Application Made: (If yes,dcit'e__ 'No El F New Construction: Yes E] No C] FHA/VA: Yes 0 No Ell <br /> TYPE:OF INSTALLATION AND SPE641CATIONS: <br /> (Noseptic tank or cesspool pWrmitfed-if-rublic-sewer is available within 200 feet.) <br /> .640 <br /> Septi' ank: Distance from nearest well--- ....Distance from f py nd 45 ion------------/O.Material----- ----------- <br /> No. of compartments_____ --------Size- iq,id cl,pth-------- Capacity..12_0--- <br /> Dispo's Field: Distance from nearest weil'._v4t4_.Distance from foundation...../A---- ---Distance to nearest lot line--- <br /> ., - .0 e Number -------------- <br /> of lines Length of each Ii ne-_W104!�- Width of trench_..._ 1011 --ir, <br /> L Type of filter material-- Depth of filter material-____ --- Total length--------466---------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____._._________ Q <br /> j ❑ <br /> ine----------------- <br /> ElNumber of.pits---------------------Lining material------ -------------- -SiLe- Diameter----------------------- Depth-----.-------------------------_- Do-, <br /> t L.A I <br /> Cesspool: Distance 'from nearest well___-___-_.-_____Distance'from foundation--------------------Lining material____..__________.__.__._____---__._-. <br /> Size: <br /> aterial-------------------------------------- <br /> Size: Diameter-------------------------------------=De th--------------------------- ----- - -- --------Liquid Capac4y----------------------------gals. <br /> Privy; _1`-. ---- <br /> Distance from nearest well-_ -------------- ----- -------------Di <br /> sfan'ce from —------------------ <br /> Disfariceto nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling. and/or'repairing (describe]___________________-- ------- <br /> --- ------------------­-------­-------------------------------------------------------------W---------------------------- <br /> -----------------------------------------------------------------------------------------------------WW-------------------WW---------------------------------------------------------------------------------------------- <br /> r. <br /> -------------- ------ -----------------------------------I--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - .. . r�� I <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) -- <br /> - <br /> - ----- /or <br /> Contractor]ontractor] <br /> By ------ - --- -----------Titl -------------- - - ---- - __ <br /> [Plot plan, showing size of lot, location of system in relation wells, buildings, c can be placed reverse S.side]. <br /> FOR DEPARTMENT USE ONLY <br /> P4 <br /> APPLICATION ACCEPTED BY -------------------------------------------------------- DATE......2--------- <br /> REVIEWEDBY--------•---------------------- -------- ......W-------- -------------W-- ------------------------------------------ DATE---------------------- <br /> BUILDING PERMIT ISSUED------------- ---------------------------------------------------------------------------------------- DATE---------- <br /> Alterations and/or recommendations:------------------------------------- ------ - -----••-•--•----•---------------•----------------------•-----•• -------------------------- <br /> ----------------------------------------------------------------------------- ­-------------------------- -------------------------------------------------------------------------------------- --------------------------- <br /> -----------------------:--------------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------ <br /> ----------- ---------I---------- -----------------------------------------------------------------------------------:------------------------------------------------I------------------- <br /> ------------------------------------------------------------------------ -- ------------------------------------------------------------------ ------- -------------------------------------------- --------------------------- <br /> 0Z_ eyl <br /> FINAL INSPECTION ------------ Date <br /> - <br /> ------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 F.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-S9 2M 3-63 F.P.CM <br />