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N � Permit No APPLICATION FOR NITATION P MIT <br /> ` l7 <br /> (Complete in Duplicate) - <br /> Date Issued ---- ••---- -,,y'" <br /> t 7 <br /> pplica i11—4 on is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein cribed. <br /> is application is made in compliance with County Ordinance No. 549. <br /> - t' <br /> JOB ADDRESS AND LOCATION ° "--------------- •-•-- <br /> Owner's Name �1 � Q!'w�' -•--•- ............... Phone. - <br /> Address------------- t r ' {--•-------------------------------•--------------------•--------------.-----.------------- <br /> Contractor's Name.. -• •---•---•----------------------------------------- ---............................................ Phone-4.d.-�•?1��� <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ <br /> '�/ - 1 f_ -------------------------- <br /> Water <br /> ------. <br /> Number of living units: -1..... Number of bedrooms _____... Number of baths ...�___ Lot size ..... .. ....... .. __.._....._____._ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 2"'New Construction: Yes g? No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic T nk- Distance from nearest well-----------------Distance from foundation...................Material................... . <br /> No. of compartments--------------------------Size...........-.. .._..._---_.-•.Liquid depth------.----.-------------Capacity--.----------------------- <br /> ejos4al5ielcl: Distance from nearest well:...............-Distance from foundation___-__-----._--•-_-.Distance to nearest lot line........:......_. <br /> Number of lines-----------------------------------Length of each line................__.-----------Width of trench-------------------................ <br /> Type of filter material-____ r------------Depth of filter material------------------.....Total length................................ ' <br /> s <br /> Seepage Pit: Distance to nearest well-14.0 .........Distance from foundation---1.0...........Distance to nearest lot line�� � f` <br /> Number of pits---.t-----------------Lining material._r'_k--___---.Size: Diameter_.--3-0-`�`.__ _._:Depth.__���_._ ._._.�: <br /> esspool: Distance from nearest well____._-_______-_Distance from foundation __ _Lining material-__ 1 <br /> -- <br /> ❑ Size: Diameter------------------------.............Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> ar F <br /> Privy: Distance from nearest well---------------------------------------------_ nearest building from e e g_---_---_--_------------------------__---- <br /> ❑ Distance to nearest lot line----------------------------------------------------------_--•-•- ----------•-•------------•----•---•------•-------•-----------•-------- <br /> Remodeling and/or repairing (describe):_.___' __________ _ � <br /> -- � <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 laws, and rules and regulations of the San Joaquin Local Health DiArict. <br /> (Signed)...-- ... ......... -­------------------------- <br /> - ------ ----------------- ---------------------------------------------------------------------------- -------------(Owner and/or Contractor) d <br /> B • "�-- �S t-- - ---------------------------------•---------------------------------.(Title) ------------ <br /> Y -ov, --- <br /> (Plot plan,"showing siie # tat, locatiw-of systenrin relation to-wells;buildings, etc., can be placed on revs side).'�`�' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_, -- -------------------------- ------•-•--•-•------------••-••---•------• DATE...V%.k <br /> •----•-- ........... -------------------- <br /> REVIEWEDBY------------------------------------- ----- -- . DATE------ ----•-----....---••---------------------- <br /> BUILDINGPERMIT ISSUED------•--•--•-•.... ............•-•-•---••••---------•----------•-•-••-•----••-•-••-------•--••_.. DATE-------- •••................. <br /> Alterations and/oromm ndati ns + • •--------------1--1•-11---------- <br /> -� ,; ' A ......--•--•-------•-•--•.................... <br /> ----11.1--------------------------------------�----.---1111--- <br /> ..... .--•••••.--•-.-•-•----••-••.. <br /> -----------------------------••------------------------ ---•-------/--------..-..------------------------.- ..............------------...---.--- .------•-•••---•-••-•-•-.••..- <br /> *FINAL INSPECTION BY:. l f-------- --- -------------- Date,....U-- pk,f ..--------------------.-------• <br /> SA 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 145446 ATWOOD <br />