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FOR OFFICE USE <br /> Permit No. <br /> APPLICATION POW-&6NITATION PERMIT <br /> Date Issued ... <br /> ------------- ----------------------------------- (Complete in Duplicate) <br />----------------------- -------------------------------- IThis 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 /> ---------- <br /> -----------­------------------------------------------------------- <br /> JOB ADDRESS AND L CATION... ------ ---------------------- -------------k IIII <br /> ---------- PhoI Isgr <br /> .. .................... <br /> Owner's Name------------- I------ - -- - -- - - -- -----------------�:------------------------­­­----------------------------------- ..... <br /> ............ ....... <br /> Address------------_- ---------------------- ............. ............................................................................ ....... <br /> ---- Phone, ......... . <br /> . .... .... ............................... <br /> Contractor's Name_ <br /> Installation will serve: Residence ❑ Apartment House ❑[I Commercial ❑0 Trailer rt El MOI D Other <br /> bathh;" <br /> Number of living units: -------- N mber of bedrooms -------- Nu b-o-r—of -4 - __4siZG ----------- -------------------------- <br /> rs._____71 <br /> Commune system 0 Private [-] Depth to Water Table!.M. it. <br /> Water Supply: Public system ��g <br /> Sandy Loam El Clay Loam <br /> []L�Clay [D Adobe E10"OHardpan 0 <br /> Character of soil to a depth of 3 feet: Sand [] Grav;l [I k - I <br /> Yes jK s ❑ No El <br /> , �N, <br /> Previous Application Made: (if yes,date-------------------- No 0 New Construction 0' FHA/VA: Ye <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool perinifted if-public sewer is available within 200 feet.) <br /> Septic T k: Distance from nearest weI60% -_-._--.`Distance`Distance from foundafion/A..�.........Materiao----- .................... .............. <br /> 6 A ; pacity... --------- <br /> P; n No. of compartments--------A------------ Size__,V_X__J_i0----------Liquid dep."th---41-7.,X-4---------Ca <br /> ..._-Distance Ito nearest lot line-/.!94..... <br /> Disposal,Iliielcl: Distance from nearest Distance from -T- <br /> .................... <br /> trench.-----24KII <br /> Number of lines---• -'Length of ea8h,1i`ne-------- ........Width of t l <br /> .4 1 nce to nearest <br /> -'rial <br /> Type of filter material. -IDepth of filte�r �nd�e Total len`gth------- •- <br /> e_,] .19 ' ­� k st lot lineZII <br /> See Distance to nearest wall I-------;Distanc M'f6u,ndA;ion__/.Av_ __.Dista'" <br /> Lining r p <br /> Number of pits.---/-------------- material. ._ - A�,..Size: Diameter-.- De -------------­ <br /> 9�_ I ;�10 <br /> Cesspool: Distance from nearest well----------------;Distance from foundation--------------------Lining m ................... <br /> material.. <br /> ------ !71 <br /> l` gals. <br /> -----------------------s----Li Ca -------------............ <br /> ❑ Size. Diameter-----=--------------- ----------------Depth-------------t��,--------­--- I <br /> I �/1Y I building----,-.----j�------------------------------ <br /> Privy: Distance from nearest well----------------------------------------------:---Distance from nearest build' <br /> Distance to nearest lot line-----------------------------------------:t-------------------........ ..................----------------------------------------- <br /> ✓ <br /> ................... --------------- <br /> Remodeling and/or repairing (describe):---------------------------------------------------- ±-•-•------...----............ . ..................... <br /> 1 1 4 *f. I �� ------------------------------------- <br /> ------------------------------------------------------------------------­­--------------------I--------- -- ------------- ----­------------------------:*--------- <br /> -------------- ------- F", <br /> ------------------------------------------------�­--4_-.____.....-_.------------------------------- <br /> ------------ -------------------------------------------------------------------------- .0(_ I .:w ------- <br /> I -k....................:------------------ <br /> ----------- <br /> ---------------------------------------------------------------------------­---------­-------------- ----------------------------------------------- <br /> I hereby certify that I have prle��aced this application and *I the work will be done in accordance with San Joaquin County <br /> ordinance 6, an les and regulatioris off the'. San Joaquin Local Health District. <br /> t- --------------­ wrier and/or Contractor) <br /> _11_ ------- ----------- <br /> 11D*e 113W <br /> (Signed) <br /> By:.......................................... - -- - ------ - - <br /> ---------------------------------((Title)-------an ------------I..............•------------ <br /> (Plot plan, showing size of lot, location of system in relaii o wells, buildings, etc.. Sb� placed reverse side). <br /> J6 <br /> FOR DEPARTMENT USE ONLY <br /> DATE. <br /> ----------------------------------------------- ------------ 7 ------------------- <br /> APPLICATION ACCEPTED BY------- ----- . _!�� <br /> I ---------- DATE-----------------------------------•--------------•------- <br /> REVIEWEDBY---------------------------------11------- --------------- ------- -------------------------------------------- DATE.. <br /> --------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------_-------------I------------------- -­------------- ----------------------.. <br /> Alterationy and/orcommendations:-------------- -------- ----- --------- ----------------------------------------------•---•--•----- <br /> .......... ....................... <br /> -- -- .... ... <br /> i ......... --e ----------- --------I................................................. <br /> ........... ------- ------- <br /> . . ...... .. ----------------------------------------------- <br /> ------------------------------------------------------------------------------------------------- ---------------------------- ...... <br /> --------------- ----------------------- ------------------------------------------------------------------------ -------­------------------ <br /> ---------------------------------------------I----------------------------------------------------------------------------- <br /> ---------------------------------- ------------- --------- ------------------------------------------ - <br /> ------------------------------------------------------------------------- <br /> ................ --------------- <br /> FINALINSPECTION BY:.--- -- -----------------------------I------------•----- Date--------------f ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Es 9 REVISED 0-59 2101 5-61 ATLAS <br />