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APPLICATION FORANITATION PERMIT Permit No. _7�........... <br /> (Complete in Duplicate) Date Issued <br /> A r <br /> This <br /> is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Is application is made in compliance with County Ordinance'No. 549. <br /> Z�JOB ADDRESS AND LOCATION_- -- --U---- ------ ---------------•------,-I--------------------- ------ <br /> Owner's Name__". _t'. -------- ----­�_.!���------------------------------------------- ------------------------I------------- PhonA ---------- <br /> Address.-_;Nge------ =..........t------ <br /> ...........................---------------- ----------------------------------------------------- <br /> Contractor's Name_..____ ------------------------------------------------------ -------- ------------------------------------------------- <br /> Installation will serve: Residence Q'/Apartment House [] Commercial E] Trailer Court E] Motel [j Other ❑ <br /> Number of living units: ___j___ Number of bedrooms Z--- Numb;r of baths __-I-__ Lot size -------570------ ------------;--------- <br /> Water Supply: Public system BK-6ommunity system E] Private E] Depth to Water Table -------- ft. <br /> Character of soil to a depth of Meet: --iSand,[] "Gravel'o Sandy Loam El Clay Loam [I Clay El Adobe L]' Hardpan E] <br /> Previous Application Made: Yes [] No ' New Construction: Yes M"'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--'---,--,--------------Materiai-------------------------------------------------- <br /> No. of com'partmenfs--------------------------Size--------------------------------Liquid de.pjh:-------------------------Capacify_--------------------- <br /> Disp;osap',Fiel Distance from nearest well----—---Distance from foundation Distance to nearest lot <br /> well..____'-". --- �ine---- <br /> .......r ) i- -i `--Width of french Z <br /> Number of lines_____- ---------------- ------Length of each:lt'ne----- ------------------------ <br /> Type of filter material$lz Depth of filter material_____IZ_r_ :7_Tofal lengfh__________ .----------- <br /> ---------------- <br /> 1 '7 1--, 1 ; <br /> Seepage Pit: Distance to nearest well----------------------Distance from founda on------I-------------Distance to nearest lot line------ -------- <br /> Number 6f,pifs.----------------7----Linin material-----------------------Size: Dia`mUer—----------- --------Depth------------------------ <br /> 9 --------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--.-_---------- material_': ..-_____:__- ---------i--------- <br /> 1-1. Size: Diameter--------- -------------------- -------Depth------------------- -----------------------------Liquid Capacity----- --------------'--gals, <br /> Privy: 4 Distance Irrorn nearest well---------------------------------------------L''._Disfance from nearest building--:--,.---------------­------I---------- <br /> EliDistance to nearest lot line------------------------------------ --------- -------------------------------------- ------------------------------------- ----------------- <br /> Remopleling and/or repairing (describe):---------- ------ -I-------- ---------- <br /> -------------------- --------------- ..........h-(•........ -- ------- <br /> -------------------------------------------------- ---------------------------------------- --------------------------I------------------------------------------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)------- �_�-- -------------------------------------------- --------------------------- ---------------------------------------------(Owner and/or Contractor) <br /> By:................19:_ -------- -; -------------------------------------------------------------------------------(Tif le)---------------------------------------------------------------- <br /> (Plot plan, showing size o 16f. iocationthi system in relation to Wells, buildings. efC., can be placed on reverse side), <br /> 4r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ------------------------------------------------ DATE_V1------------------ <br /> REVIEWED BY ------------- DAr <br /> E --------I----- --------------- - - <br /> BUILDING ----------------------------------- <br /> PERMIT ISSUED-------------------------------------------------------------------------------------------------------- DATE-----7iE�------- <br /> Alterations and/or recommendations:------------------------------------ --------------------- --------15 <br /> -------------------------------------- .....----------------------------------------- <br /> -----------------------------------------------------------------------­­­­--------------------------------------------------------------- ----------------------------------------------------------------------- <br /> -----•-------------------------------•-------------------­­---------------------------------------------------------r----------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- -------------­­------------------------------------------- -------------------- ------------------------------------------------------------------- <br /> ---------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-.--- ---- ----- -- ------- ------- Date--.------ ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef <br /> Stockton, California Lodi, Cal;fornie Manteca, California Tracy, California <br /> FS-9-2M Revised W-2100 <br />