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FFICE USE: <br /> --------------------- ------- <br /> = (Complete <br /> APPLICATION FOR tAAIfX- TION PERMIT Permit.No. ....... <br /> ---------- ----------------------------- <br /> (Complete in Duplicate) Date Issued ---- <br /> -------------------- <br /> ------ -------I------ This Permit Expires I Year From Date Issued <br />------- -------------------------- ------------------ -- <br /> Application ishereby made to the Son'Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is ma;Ie in compliance with County Ordinance No. 549. <br /> ------------------------------------------------------- <br /> L ADDRESS AND OCATION------ -- ---- --- ------ - <br /> JOB -------- -------- Phone------------------- <br /> ------------ <br /> ---------------------------- ----------------- --- - -------------- <br /> 'me - ------------ <br /> Owner's Name---- -------- - . - <br /> --------------------------------------------------------------- <br /> ---------- ------ ­----------------------------------------------------------- <br /> Address----- _ . .. I <br /> 's Name___._____.---------- - - - - ------ ------------------------------------------------------------------------------------- Phone ...... <br /> ContractorCommercial [] Trailer Court [I Motel 0­_Ofh_e`A���. <br /> Installation will serve- Residence 0 Apartment House 0 Com <br /> Number of living units: __7T_--7Number of bedrooms Number of baths.-Z—__.'Lot.,size 1j0wfX <br /> Water Supply: Public system 0 Community system jgj' private IST'Septh to Water Sandy Loam [I Clay Loam [] Clay E] Adobe ga P <br /> T'able -11ard an 0 <br /> Character of soil to a depth of 3 feet: .,Sand F-1 Gravel E] PHA/VAI Yes Z�-,No El <br /> Previous Application Made: (if yes,date------ -------------) 'No Z��New ConstE- <br /> .ruction: Yes IN o [I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> from folundation--z --- <br /> Septic Tank: Distance from nearest well,//121---.Distance K -_�v .1 C a <br /> squid clep�h__ pacify <br /> No. of compartments-- ------ - -- - - I7Ki--------------- . .... <br /> I - nearest lot liine_�O ..... <br /> Oj .-Distance from foundation---1,49-1------Distance to <br /> Disposal Field: trench. <br /> from nearest w ---------- <br /> - ------------ Length of each ---------------Width of frencl <br /> Number of lines- <br /> 0 --- <br /> _,o.e--------..Total length__�� <br /> Type of filter mat&ial,/__ ---Depth of filter materia411 <br /> Ir rest lot line4�`* ..----- <br /> Seepaq Distance to nearest well--,,- Distance f om W I <br /> r foundation__ _--------Distance to nearest <br /> e Pit: <br /> ng material- 4.0 ---Size: Diarneter_..,.� -----Depfh-,:g, <br /> -Number of ---------------Lini m <br /> P11, P"111 ------1ining material------_--------------------- <br /> Cesspool: -Distance from nearest well---------------- Distance from foundation------------- ----------------g'Is. <br /> �Si ----------Liquid Capacity- ----------- %0 <br /> Size: Diameter-------- ---------------------------- Depth---------------:--:------------------- --- <br /> C1 i I ... <br /> Privy: :Disfae-f5c Arom nearest well---------------------- - <br /> ---------------------Distance from nearest building------------------------------- ---------- 0 <br /> ----- ---------------------------------- <br /> • <br /> --------------------------------------------- <br /> Distc)nce to nearest lot line---------------------------------------------------------------- <br /> --------------------------------------- <br /> .., . <br /> Remodeling'and/or repairing ------------- <br /> --------------------/--------------------------------------------------------------------------- <br /> ----------------------------- ---------------------- <br /> --------------------------------- <br /> ----------------- ----------------- 0 <br /> ------------_______________________F_-._- - � --------------------------------------------------------------- ------------------------------------------------------- <br /> --------------------- ------------------------- ------------------------------------ --------------------------------------------------- ----------------------- ....... ..... <br /> • --------------------------------------------------------- h San Joaquin County <br /> .- <br /> _________ _______________________________"_"---_---_.--._---_------------___---------- <br /> hereby certify that I have prepared this apiplicati6n and that the Work Will r be done:in accordance with <br /> ordinances, State laws, and ales and regulations of the San Joaquin Local Health District. <br /> 3 1, 0 <br /> ----------iT'f-le <br /> (evraeriA�r Contractor) <br /> -- ----------------------------------- <br /> -------- ---- - <br /> (Signed)------------------ <br /> ---- ----------- <br /> . ................. <br /> - --- - --- - - - --------------------- <br /> By:------------------------------------------------ ------------------------- - - - <br /> locat,"n of system i ation to wells, buildings, etc., can be placed on reverse side]. <br /> (Plot plan, shoWing size.of lot, 10 <br /> FOR DEPARTMENT USE ONLY - <br /> .0 <br /> DATE------ --- ------- ------------------ <br /> ACCEPTED BY----- --1!:� --------- --- - -------------------- <br /> APPLICATION ------ DATE.----------------------------------------------------------- <br /> -L------------ <br /> APPL CATION ACCEPTED ED Y <br /> R p�-V I FW K y ... ------ ---------------------------------------------------- <br /> EVIEWED ----------------------- ------ ------------ DATE.----------------------- -------- ---------------------------- <br /> -------- ----------------------- <br /> BUILDING PERMIT.!�IISSUED----- --------------- ------- --- --------- <br /> -------------- ------ <br /> Alterations and/or ecommendatio.. ? <br /> r -------- <br /> ------ ---------------- -------- ---;L <br /> -------------------------- - -------- ---- --I �<I-------------------- ------:---------- <br /> ----- 1_11. __Ix -------- --------I------------------------- ------- - <br /> ------------ ...... ---------------------------------------- <br /> -----------------------------_--------­-- --------------------------------- ------------------------------------------------------------------------------------------------------- ------------- <br /> ---- ---- ---------- -------- ----------------------------------- <br /> ----------------------------- ------------------ - ------- -- ---------- ------------- -------------- -----­----------:---------- <br /> FINALINSPECTION BY:---- ---------------------- ........ ------- pate_ ..... -- -------------------------------------- --------- <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West.9th Street <br /> ia California Tracy,California <br /> Lodi,californ Manteca, a I ornia <br /> Stockton,California <br /> iS 9 REVISED 13-59 3M 3`63 <br />