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Permit No. <br /> APPLICATION FOR PERMIT -----7J�.... <br /> Aj\ lComplefe in Duplicate) <br /> Date 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 L-QCATION---------4� -- -- --------- -------- - <br /> Owner's Name------ — ---------- -- -- ---------------------- - ------------------------- Phone <br /> Address,.---- - <br /> Contractor's Namee; -------- -------------------------- <br /> ------ <br /> -------------- Phone <br /> Residence Apa merit House E] Commercial E] Trailer Cop r <br /> Installation will serve: Court ❑ Motel Other <br /> Other er El <br /> Number of living units: _/---- Number of bedrooms - <br /> Number of baths __/__ Lot size <br /> Water Supply: Public system)Rr Community system El Private E] , Depth to Wafer Table ��ft. <br /> Character of soil to a depth of 3 feet: Sand Ej Gravel [] Sandy Loam E] Clay Loam [] Clay El AdobeX Hardpan ❑ <br /> Previous Application Made: Yes L] No K New Construction: Yesg No El FHA/VA; Yes E] No.. <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> pp!ic Tank: Distance from nearest weil Distance from om foundation--------------------Material------------------------------------------------ <br /> ' - g 4112L. No. of comparfments.�----------- ------------Size--------------------------------Liquid clejpth---------------------------Capacity----------------------- <br /> DA;6s,pp,.Asal F' d: Distance from nearest Distance from foundation---_%-----------Distance to nearest lot line___-,-_____-- <br /> Number of lines 10 1 <br /> 4ala. - ------ - Length of each lin---------4-----------------Width of french------1__2------------------------- <br /> a_teria_l_____ZLt1_____ Depth of filter material_____- ...........Total length------- <br /> Type of filter m <br /> See pa Pit: Distance to nearest well, .J____Distance from unc1ation__,4,!�9__+__'..Distance to nearest lot <br /> J11 <br /> Number-of pits--------/-----------Lining material_�'-ZrZ------Size: Diameter-.,Z?--,r---------Depth-- - - ------ - ---------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-------------------------------------- <br /> ❑ Size: Diameter-------------------------------------Dept h----------------------------------------------------Liquid Capacity------- --------------------gals. <br /> riv Distance 'rom nearest well.-.-' CA <br /> ---------------------------------------------Distance fro' m nearest building---------------------------------------- <br /> ElDistance to nearest lot line---------------------------------------------------------------------- --------------- <br /> Rernode an or repairing (describe):---- <br /> 1111-4-- - - - - - ---------------------------------------------------------- --------- --------------------- ------ -- ----------- --------------------------------------------- <br /> ----- ------- <br /> -- ----------------------------------------------------------------;--------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------I----------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ <br /> --------- <br /> I hereby certify that I have prepared f his.application 'and that the work will be done in 'accordance with San Joaquin County <br /> ordinances, SKe laws; and rules and/egulations, f the <br /> Y/1an Jo uin Local Health District. <br /> (Signed)---- --- ..... --- -- - -------- --- -- <br /> ------------------- (OwneLrvVor Contractor) <br /> ---------------------------------------------Title = ------- ----- <br /> (Plot plan, sow lot, Iota of system A --------------- <br /> in to wells, buildings, etc., can be on reverse si <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY___i______________ ---------------------------------------------------------- DATE---- <br /> ------------------------------------ <br /> REVIEWEDBY------------------------------------- .. .. ----------------- ------------------------------------------- DATE-------;--------------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------ ---- ----------------------------------------------- DATE-. <br /> Alterations and/or recommendations_________________-- - j I <br /> - -----------------------------:-------------------------------------------------------------------------*------------------------------- <br /> ­1�------------------------------------- ------------------------------------------------------------------------------- <br /> ----------$----- ----------------------P--*- - -------I-,- <br /> -------------------77(_�.. ;1-------- -------- <br /> - .I------- - ----------------------------------------------- --------------------------------------------------------- <br /> --- <br /> I <br /> -------------------------------------------- ------- ----- -------------------- ------------- -------------------------------------------------------------------------------------------------------CK­ <br /> FINAL INSPECTION BY:---------------------------------------------------------------- Date---------------------------- t <br /> SAN <br /> ate----------------------------- <br /> SAN 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-9-2M Revise(j 1.57 F.P.CO. <br />