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1 � <br /> APPLICAT19N FAANITATION PERMIT Permit No. ._�U../- .1_.. <br /> (Complete in Duplicate) r "'If <br /> 9� Date Issued ___._.../ <br /> Applicafion is hereby made to the San Joaquin Local Health District for a permit to nstruct"and install tbd work`herei described. <br /> This application is made in compliance County Ordina No. 549. <br /> JOB ADDRESS LOCATIO --- --- ------ - -..-- -�f- ; y / <br /> Owner's Nam - - 7 � <br /> Address - .� O Q _ <br /> -_---- ----- <br /> ----- ---------------- ---- ------ --- „ ---- <br /> Contractor's Name y <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Oi4r ❑ � <br /> Number of livingunits: __'___ N 'ember of bedrooms __ ___ Number of baths _ /_..._ Lot size y� - - f s e -----•-------- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth t&Wafter Table ----- ft <br /> Character of soil to a depth of 3 feet:; Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam y ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes o New Construction: `(es <br /> Pf ❑ ❑ E] NQ FHA/V : Yes ❑ mpg* - <br /> TYPE OF INSTALLATION AND SPE IFICATIONS: . <br /> (No septic tank or'cesspool periniffed if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well - Distance from founda lon 1.._.. ?trial <br /> ` No. of compartments----- __...Size...__._� ._ � _Li uid' depth_ r Ca act 19__c'1 <br /> Disposal Fuld: Distance from nearest well,,,-�.Distance.from foundation /y` ------------Distance:to nearest lot One <br /> Number of lines......-.: _- __ _______Length ch line-------- --------Widths of trench ._.._.__ <br /> ---- <br /> Type of filter material __ __ <br /> _ _________Depth Of filter material _ _- `r Total ength------_ ` <br /> ��a� -•- <br /> Seepage Pit: Distance to nearest well -_______-_Distancer'trotn foundation...._...............Distance tF nearest Ytline <br /> ❑ Number of pits________ __________ Lining material..__ ,------------Size: Diameter------------------- Depth---------f----------------- <br /> Cesspool: <br /> .______-. ___Cesspool: , Distance from nearest well-----------------Distancetfropn foundation-----------------_Lining material �_ _. <br /> ❑ Size: Diameter--------------------------------------Depth----- e ­------------------ - Liquid Capacity ..----_- gals. <br /> Privy: Distance from nearest well-------------------------------- __________Distance from nearest building____-_-------- --_--------------------- <br /> Distance <br /> --__ -.Distance to nearest lot line-------- ---------- --------------------------------------------- ------- ----- <br /> / , <br /> Remodeling r re -a--in esc / <br /> , ' <br /> ----------- - ------- - §..... . ,5 <br /> ---1 - - <br /> --- ---- ------ - -- --- ----------------- -----------------•-- - - ----I- <br /> I hereby certify that I h e prepared this application and that 1her work will be done in accordance with San`Joaquin County <br /> ordinances a la nd ules d r ul tions of 4 San Jo in Loca ealth Distr'rctt <br /> Z(Signed). •--- ot�c ----- '`:mss `� "�a= '-, (Owner an r Contractor) <br /> / .� <br /> gY• - ' = ---------------------------------- <br /> - <br /> - ------ (Title),,,- <br /> ----------------- <br /> (Plot plan, showing size of to , locat on of system in relation to wells, buildings, efc.r-ftrt be placed on leverse aid <br /> R OEPARTMEt�(`I USE ONLYlit <br /> j <br /> APPLICATION ACCEPTED BY-__ <br /> ---- ---- ---- -------- ------------ ------ DATE ---- <br /> REVIEWED BY------------------------ --- -_-------_---- ------ - .........----------DATL= . <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------------- -------- DATE----------7-1i ........ <br /> Alterations Qnd/o! ec!" ndatiorvs: -- °p <br /> - -- ---- .............................................n -1 h-- -- <br /> l 1 Z l S <br /> . . <br /> -------------- ------------------ ---- --•--- <br /> ---------------------------- ------------------------------------------------ -------- ----- ---------------------------------------• ----- ------------•------ •--•---•------------- --------- <br /> ....._. ` - ------------------- ----- --- .........------------------- -----------------------------------------------" <br /> ------ <br /> FINAL INSPECTION BY:._____: `�`� ---- ------- ------- Date---,-/� �f � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 SycamoreStreet 614 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised 1.57 VP.CO- <br />