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APPLICATION FOR SAN"T PERMIT R r, Permit No. <br /> r"� '* y <br /> r (Complete in Duplicate) 4 S Z - S <br /> LA Date Issued l <br /> Application 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 Ordinance No. 549. <br /> JOB ADDRESS AND L CATION--- �� 4 . --------------C)/ --------------------- <br /> Owner's Name------.f4FZd//6 ------------ (,r7 ------- Phone--------------------------- <br /> Address �eAr I. <br /> td_e / --------/fQtld-.-n---IY4-;91 -- -- ................................................ <br /> Contractor's Name.__.,4_A*....... /^� �t -/--------------- ------ Phone�._.--"1 _4 �------ <br /> Installation will serve: Residence^ Apartment House E Commercial ❑ Trailer Court ❑ Motel L] Other 171 <br /> Number of living units:OYU-Number of bedrooms.4-. Number of baths _f--_.- Lot size--&_:'A f Q-a___ <br /> Water Supply: Public system K 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)& New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well __._Distance from foundation....................Material-------------------------------------------------- <br /> El <br /> __-_-.-_ _-_---__--.❑ No. of compartments------------ ----Size--------------------------------Liquid depth -_ --- Capacity ---- <br /> Disposal Field: Distance from nearest well -_-__.__:Distance from foundation_______________ __Distance to nearest lot line................. <br /> �' <br /> ❑ Number of lines___________________________________Length of each line--------- --.._._........Width of trench_______•-_.__-________-_______-_--, <br /> Type of filter material______________ Depth of filter material -____. Total length-----. ._.._-__ <br /> • <br /> Seepage Pit: Distance to nearest well----- <br /> Distance from foundation.,�e-------- is a e to nearest t hie_�su��_-_. <br /> Number of pits_OH-l.�-.......Lining materia l-_ 5Kf4X,__Size: Diameter�D„"Z.-__-___._-.Depth...�?_______________•___-__ <br /> Cesspool: Distance from nearest well-................Distance from foundation------------.....-_.Lining material_- _---__._, _----_.._.___..._... <br /> ❑ Size: Diameter--- ------Depth--- -------------------------------------------Liquid Capacity ------------------..-----gals. <br /> Privy: Distance from nearest well_____________________ _________________________Distance from nearest building------------------------------------------ <br /> El <br /> .--__ _____-__-__._._---____ __--_-__:❑ Distance to nearest lot line---------------------------------------------__-----------------------------------------------------------------_.........--------------- <br /> Remodeling and/or repairing (describe):._____ _r_ ____-_ __-t---- _ <br /> ----- -- - - - •-- <br /> ------------------------------- <br /> ----------------------------- -------- -------------------- ------------------- ----•----------------------------------------------------------------•------------------------------- ---­­--------- <br /> 1 hereby certi that l have prep d this application and that thew wiN be done in accordance with San Joaquin County <br /> ordinances, Stat s, d rules a r gulations of# San Joaquin LowHealth District. <br /> - - - - ------ --- -------- f (Owner apd Con actor) <br /> (Signed) ---------- 6- <br /> BY: "� s (Title) <br /> -- -------- ....... <br /> ---- <br /> (Plot plan, showing size of to , location of system in relatio to wells, buildings,,etc., can be placed%n reverse side). <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y.. - ---------------- DATE -------- -------=_---_------------- <br /> REVIEWED BY-----------_--------- -----•----- -- - DATE .... ..... <br /> BUILDING PERMIT ISSUED--- ------------- ------------ ------------------ --- ------- --------- -------- DATE----------------------- <br /> Alterations and/or recommendations:-- ----•-------- ------ ---------------------------------------------------------------------------------- --------- ----- -------- -------- <br /> ------------------------------------------------------------------- ----- ---------- ---- .- ------------------------------ <br /> FINAL <br /> ----- - -------FINAL INSPECTION BY: / <br /> Date ------` -- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 SycamoreStreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca,California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />