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. '� APPLICATION FOR $AIr1tTATIO _PERMIT <br /> Permit No. -- --4?-- -----j <br /> (Complete in Duplicate) / ` <br /> Date Issued .- ......l 3---•- <br /> Applica+ion 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 OrdinanceNo. 549. <br /> JOB ADDRESS AND LOCATIO _.. .--- `5 c <br /> Owner's Name------------ '/.� Phone................................ <br /> Address_ - <br /> ------• --•--•..........•-••--•- ---- -----------•-- -•-•--. -------- --------- ------------------------------ <br /> ------- <br /> ..-•--.-•-- ••. --_. <br /> Contractor's Name. A ------------------------------------- ------ Phone. _ _ <br /> r' * ---- -------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court-❑ Motel ❑ Other ❑ <br /> Number of living units: ;��munity <br /> _ bar of bedrooms .Gt�'.. Number of baths -�__- Lot size.....7 r �-� <br /> Water Supply: Public system system [2 'Private❑ Depth to Water Table 4/Q. ft. , <br /> Character of soil to a depth of 3 feet: (Sand'❑ ravel ❑ Sandy'Loam lay Loam ❑ Clay❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ Nt New Construction: Yes' No ] <br /> TYPE OF INSTALLATION AND OEC [CATIONS: <br /> (No septic tank or cesspool perrrEtted if public sewer is-available within 2W feet.) <br /> tienj: Distance from bearest well------ ______Distance from foundation.-..................Materia------------------------------------._...-_.__... <br /> No of compartments_--___ Size----------- ------_ __-...Liquid depth -------:-___-_..Capacity.. . <br /> iso FR Distance from nearest well --------------- Distance from foundation)......... .._--..Distance to nearest lot line................. <br /> .p <br /> Number of lines-__ I-----------.---------------Length of each line..............................Width of trench................................... <br /> Type of filter material________________________Depth of filter material.-:--------------------Total length__....._ .__.._.._._...... <br /> i - / <br /> Seepag i : Distance to neerest;well /h, 6�-_-Disiance�°fpr�om foundation .s. _ Distance to nearest lot line ls-....___. <br /> Number wits._.. _.�--------__-Lining materiaL_� ize: Diameter-_:" 1_*.......Depth--------AS............... <br /> Cesspool: . Distance from rnearest well-----------------Distance from foundation Luning material__- _______- <br /> ❑ Size: Diameter------------------------------------Depth------------------ ---------- ---- ----------Liquid Capacity-------------------------- gals. <br /> Privy: Distance from nearest well--s-_` ---------------------------------------- Distance from nearest building....... <br /> . ................................... <br /> ❑ Distance to nearest lot line-- •-- -------------------------•- -•----•---------------- ---- ------•- - <br /> J <br /> Remodeling and/or repairing (describe)• t �a2 •�.--= Lei_ PA*17—4 ."�,...�................... ---------- <br /> -------------------------•------------•-----------•-•-.......................................................----------•-•--I-•-----•-•--------- •--------•-------------------- •---•-......----- <br /> ------- ---------------- -----------_-­------- •--•-•----------------------------------------------------------------------------------------------------------... --- <br /> I hereby certify that-1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws,ind rules and regulations sof the San Joaquin Local Health District. <br /> ep <br /> (Signed). ---- - ... ( and/or ctor) <br /> 9---- Contra <br /> (Plot plan, showing size of lot, location of stemyin.relation to wells, buildings,-etc., can be placed on reverse side). <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- -------• ------ • DATE----------- <br /> REVIEWEDBY ---------•-------------------------•.-• ------. -•-----• ---------- DATE <br /> BUILDINGPERMIT ISSUED................. ................................................................................ DATE...................................... <br /> Alterations and/or recommendations:. ------ ---- •-----. ------•---------••-•-------------. :-------•--•-------- ------------------ <br /> ---...--•--. ---- -------- ---•--• -•-...... ------ ---------•----------- -------- -------- ------------------- ----- -------- <br /> -4 �— -? —.�-&( <br /> ®ri <br /> FINAL INSPECTION BY-----------rAP-7e;--- 7...------------.. Date------------------------------ ...................... ......................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />