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z <br /> APPLICATION FOR SA [TAT(ON PERMIT Permit No------- r -......'_ <br /> ----- ------- (Complete in Duplicate) 3 <br /> This Permit Expires 1 Y Date I # <br /> Year From Date Issued Issued ..............�.�.._____. <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 Ordina ce No. 549. <br /> JOB ADDRESS AND LOCATION..__-. t` O <br /> Owner's Name-----l0U& �� f <br /> Phone.-/,/_d... _":(O�.�._r`� <br /> Address..------•---------=-----•--Q----------•-•- <br /> ------••-----•----------------------•--------•------------------ -------••-----------•---------------------•-- <br /> Contractor's Name --------------- <br /> •-------------•-------- <br /> •---------------------------...----- ------ Phone <br /> Installation will serve: Residence ,Apartment H <br /> ' ouse ❑ Commercial ❑ Trail Court ❑ Motel ❑ Other ❑ <br /> Number of living units: !_ Number of bedrooms _-Z- Number of baths /.,�- Lot size _-��� <br /> Water Su <br /> Public system� ��---•-------------------•--..:. <br /> Supply: Y Community system ❑ Private ❑ Depth to Water Table .___.___ ft. • <br /> Character of soil to a depth of 3 feet: Sand [] #59l Sandy Loam ❑ ClayLoam Clay El Adobe El--Hardpan <br /> art <br /> Previous Application Made: (If yes,date._!9 SS- } No [I New Construction: Yes ❑ No ❑ FHANA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br />[ (No'septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sceptic Tank: Distance from nearest well_. Distance from foundation__.__ <br /> Materiel ----------Capacity <br /> .................... <br /> ��� �7eld. <br /> No. of compartments----------------------------size-----•-----•--...---_--....._•_Liquid depth__.._. __________ _ <br /> Disposal Distance from nearest well_____----_-----_.Distance from ------_ <br /> --~Ca aci <br /> �! Number of lines______ __ Len Length of each line--- Distance to nearest lot I1 e -------- <br /> Type <br /> dr 9 •_-4_0_'-----._.Width of trench........, _��_.__ <br /> y Type of filter material._ __-- Depth of filter material_____fg.��-_--_Total len length ___ _ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation___..___.___- g <br /> err Number of pits______________________Lining material----------- -----Distance to nearest lot line__..___..__..__._ <br /> --------.-Size: Diameter---- .._...---•---Depth----_----------------••------ <br /> Cesspoo�,t� Distance from nearest well_________________Distance from foundation------------------ <br /> ..Lining material------. •--------••--••--------•. <br /> ❑ Size: Diameter----------------- -------- -----------Dept h----------------------------------------------------- <br /> ----------------------- ---- i <br /> ----------------------Li Liquid Capacity Privy: q P tY- --------••-------••-------gals. <br /> Y' Distance from nearest well._._-_--_------• <br /> ................................Distance from nearest building-__-____----------_ <br /> ❑ Distance to nearest lot line____ _ ----------- <br /> ----------------------------------•-------••------_------•---.-------- --•--- <br /> Remodeling and/or repairing (describe):---- --------- '� -z_ _ei— :Lz 1 <br /> ' <br /> . _. _ _ ----------•------•------------- <br /> -----••-----------------•-------- • <br /> -------•----------•---------------------------------------•----•-••-----------•---------------------------------------------•--------- ----- <br /> I hereby certify that 1 have prepared this application and that the work will-be done 'n accordarrce with San Joaquin"Counfy <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, <br /> " SI ned <br /> { '4 <br /> ---------------------------------(Ow <br /> :. 7� -------- ,.. (Owner and/or Contractor <br /> {Title------------------------------------------ j_ <br /> of plant showing size of lot, location of system in relation to wells,--buildings,efc..can be pladed.on reverse side). <br /> F R DEPART N7 USE ONLY <br /> APPLICATION ACCEPTED 8Y__ ----- -- - -- --- <br /> REVIEWED BY. ............ = <br /> DATE_._��_, <br /> �' -- •- -------••------- <br /> -- DATE <br /> BUILDING PERMIT ISSUED - - <br /> --- -------•- <br /> ---------------- --------- DATE.------ ................................................... <br /> Alterations and/or recommendations_________________________ <br /> -----------------------•--------- <br /> --------------------------- -- _, <br /> ----------------------------------- <br /> ------------------------- <br /> F1NAL INSPECTION BY:----- <br /> �/�.----- - 4 <br /> Date ! --------- - ' <br /> SN_JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Srreel <br /> 124 Sycamore Street 405 West 9th Street <br /> Stockton,California Lodi,California <br /> EB 9 REVISED 8-59 ?M p-61 ATLAS Manteca,California 1'ra[y,California <br /> f <br />