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FOR OFFICE USE: e�f C7 .,(� H z l <br /> .---------_---------.__----------------------- -------- APPLICATION FOR ANITATION PERMIT Permit No. . -1 ..h <br /> -------------- ------------------------------------------ (Complete in Duplicate) lv <br /> Date Issued ,G <br /> ------____--- -____-_________-___-._- This Permit Expires 1 Year From 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 Ordinance No. 549. <br /> fig <br /> JOB ADDRESS A?ND OCATION... 1_ - _I_______5_ 1 .__a._'.. �_ - ---� <br /> Owner's N me �9-y1:�"�- .� -- = 1 --------------------- ----------------------------------- Phone......................... <br /> - <br /> % <br /> _--_-'-- <br /> Contractor's Name.--------.-- ` •___-- - ---•- ': �-G_Z <br /> Phone...........................------- <br /> Installation will serve: Residence Apartment House ❑ Cmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 14 <br /> -_ Number of bedroo s _-_ ___- Number of baths .---_-_ Lot size l �__ K_' r <br /> Number of living units: ___`_ 1 <br /> L <br /> Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table J. . ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 6 Adobe❑ Hardpan <br /> Previous Application Made: (If yes,date_ -----------------) No'-V New Construction: Yes t, No ❑ � FHA/ISA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' '����' --� <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sep iG Tank: Distance from nearest well ______..__Distan f o ound on...__� Mat rial______ ______ _`�-� _-_. --_. <br /> � -----�,� f- _ <br /> No. of comp rtments_ _ ----Size..._`__ ._X_.S.Liquid d pth____ �_.___ ! Capacity_ -;_ <br /> Disposal Field: Distance from nearest well. '. %_. istance from foundation.. ............Dist <br /> ,o,pce to nearest lot``I�p-----__---_- <br /> Number of lines__.-•---___-------_--_-_-Length of each line_�Q__-2-�a �tdth of trench__ _______________________ � <br /> Type of filter material_.:UI__G°ej�Depth of filter material___.__N'-- <br /> -------Total length-------- 1J___-.._.____-_._.__-___-- � <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_-.__-____.-___-_ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------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 /> ❑ Distance to nearest lot line------------------- ------ --- ------------- •---------•-----------• -------------- --------------.. <br /> Remodeling and/or repairing (describe):--------------------------------------------------------------------------•------------------••-•------------------------------------•--•------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------- C,f <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- 4 <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 /> 0 <br /> (Signed)-------------------------- - ----------�------------ ---------------------- --------------------------------------(Owner and/or Contractor) <br /> By:.............................------------------------------------------------------------------------------------------------------(Title)------------------- ----------------------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------------------------------------------------------------------: DATE------ - ------------------ <br /> REVIEWED BY--------------------------------------------------------------------------------------- ` '' ----- DATE------- fir <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------•---------- ----------------------- DATE----------------------------- ------------------------------- <br /> Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------_--------- <br /> -------- --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- <br /> --------------------------- ----------------------------------------------------------------•-------------------------- -------------- ------------------------------------------------------------------------ <br /> ---------------------------------- ------------------------------------------------------ ------ ------------------ ----------------------------------------------- ------------------------------------------------- <br /> -- - ----- -- - - --- ---------------­----------------- ------------ -- - -- -------------------------- <br /> ---------------------------------------- ---------------------------------------- --------------- <br /> FINAL INSPECTION BY:- - ---- -- Date-.----- �I_.� _ ` �" `D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,Califoinia <br />