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OFFICE USE: <br /> �.r <br /> P <br /> - ------------ _ �. b > Permit No. _ �`- .. <br /> + - <br /> APPLICATION FOR SANIf ' 11O PERMIT <br /> ---------------- ---------------------------------------- <br /> d <br /> --------------------------------- -------------------- (Complete in Duplicate) Date Issued- <br /> This <br /> ssuedThis Permit Expires 1 Year From Date Issued <br /> lication is herebymade t� <br /> o the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> q <br /> hpspapplication is mde in compliance wit County Ordinance No. 549. <br /> l -1 p1� <br /> JOB ADDRESS AN LOCATION E S Q {/� Q Q-- ------------------------------------------------• ------------------------- <br /> � �-- - - - <br /> Owner's Name-- <br /> - ._� Ph <br /> u <br /> r <br /> Address--- ; <br /> �1. ----1.11.. ------ •----- -- - - ------------- ----------•----- -•---------•------------- ---------------------------------- <br /> v ---- <br /> _ -- --. <br /> Contractors Name..----- - - - - _ Phone.._ <br /> Installation will serve: Residence JZ Apartment House Commercial ❑ Trailer Court E] Motel [❑ Other <br /> o �C <br /> 9 --. Number of bedrooms fA_ Number of baths __� Lot.size __ --------------------- <br /> Number of liven units: <br /> Water Supply: Public3.system ❑ Community system ❑ Private X Depth to Water Table ._ZS ft. t <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay D Aclobe 5d Hardpan ❑ <br /> Previous Application Made: I!jlf yes,date---_---------------1 No ❑ NeU�wCQnstruction: Yes L❑ No ❑� FHA/VA: Yes [INo�'f <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ✓ <br /> i <br /> Septic Tank: Distance from nearest well ._...`Distance from foundation...-___�p..._.MateriaL_Co­-------------------------- <br /> i <br /> of com,partmel s Size =� .' -n Liquid depth--•-- ------- ;CapatitY <br /> I. r r <br /> Disposal Field:; Distanceifrom neares well--.L��....Distance from"foundation..-.l.�--......-.Distance to nearest lot line...__..__.. 04 <br /> -tl _ <br /> Number � 1 <br /> � "of lines-------- ----- -------------------Length of each line--------- -(7.�----------Width of trench.-��--.-------------------- ;S- <br /> - filter mater�al',�p��'ti--------Depth of filter'materlaL.....1�--__._---Total, length--___�____---------------------------- <br /> p <br /> ___________ _ <br /> ---•---------- <br /> I Seepage Pit: Distanocell to nearesttw 44-.... .�_-...Distance from foundation.--._.- Distance to nearest lot line-_�____-.- <br /> YP <br /> g i <br /> Number:,of pits------ -%=--_------Lining material- � ---.-Size: Diameter.-41Y------- --.Depth-----/ ------------------ V <br /> Cesspool: Distance f1£om"nearest"well._-_ -. =_Distance from foundation-._.-.-...... -._ Lining material------..............>--...-____..... 5. <br /> ,I - <br /> P ` Li ,u. <br /> ❑ Size: Dlameter----------------------------------- IDepth-------------------------`------- ------,"----- � f� Capacity gals. <br /> Privy: Distance.from:neast.buildi <br /> Distance from nearest well -- d % '` �r ---------------1_ <br /> ❑ Distance <br /> to nearest lot line--------------- -------& ------------ <br /> { ------------------- ---- - <br /> it i� F r ---------- <br /> Remodeling atnd/ r repairin,g (_describe):---------------- <br /> ------------------------d ----- <br /> ,,g <br /> - Rh - --'° ._ l: 5 „.----- - - - ---. <br /> 9 <br /> ----------------- <br /> I - <br /> vf`-f K. <br /> s =---------------------------------------------- :. <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordin, 5. State laws and'rules and regulations of the San Joaquin Local Health District. h. <br /> 1 `. iI '� , I_------ ------ <br /> (Sign <br /> and/or Contractor( <br /> (Signed)-r� ---���%- --- ---- --- -- <br /> of B i le # <br /> PI :)Ian. size of I-------------------•---- - - ---------- -------------- ----•-----------------•----- -----•-----(Tit, )------ - ------------;---------- ----------- ------- i <br /> at, location of system in relation to wells, buildings,, can be placed on.reverse side). <br /> ( � F showing� r <br /> 1 FOR DEP TMENT USE ONLY <br /> I r DATE--- <br /> --- ----------------- <br /> APPdICATION ACCEPTED BY--._ DATE <br /> BUILDING PERMIT ISSUED----- :----- �----------------------------------------� � -- --------. DATE.------------------;-------------------------------------- <br /> REVIEWED BY-------------- ------�---------" ------- --------------------------- ------------------------•- <br /> r <br /> Alterations and/or recommendations� :_.__._------------= - -- - --- ---- --------------•--- -••------•-.!1/� �`� <br /> ..., <br /> ; _'= 1 <br /> -� <br /> a <br /> .. ... .... ..... ......... -- --- - - ... ----- --- ----._....._ .... - ...- <br /> __ _.. __ .. --- -- ------------- --- --- _----..-_.. <br /> .. .. .. .. .. .... .. <br /> � <br /> ,. - <br /> NAL INSPECTION BY:---------- .-_ <br /> •----- Date----_--------- �-- ----- - ------ -- -- ------------- <br /> i I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> II ` 124 Sycamore Street 205 West 9th Street <br /> 1601 E.Hazelton Ave. 300 West Oak Street <br /> �3 <br /> 5lockfon,CaliforniaII Lodi,California Manteca,California Tracy,California 11 <br /> ! <br /> E5 9 REVI6EG 6-59 3M 3-•63 "'CG- <br /> Ip <br />