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APPLICATION FOR 5 1TATION PERMIT RMIT Permit Nol__ <br /> "` {.Complete in Dyplicate) <br /> r Date .Issued - �, <br /> + Application is hereby made to the San Joaquin L`o' I Health District for a permit to construct and install the'work herein described. <br /> This application is made in compliance w*h CountOrdinance No. 549. <br /> JOB ADDRESS AND LOCATION_ ____ ___._ <br /> - -------- - <br /> Owner's Name -"G. ]., --------- -- - 1 Phone <br /> ---- <br /> ------------------------------------- <br /> Address----- `� ` --------------2 ---------------------- -----------•-----•-•-•--------•-------------•-------•-_----- <br /> Contractor's Name----------------------------------- = Phone------------------------------------ <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ <br /> Number of living units: �� __ Number of bedrooms __Number of baths __ Lot size _.[_ - ________________________________________________ <br /> Water Supply: Public system ❑ Community system '❑ _Private Depth to Water Table ff. <br /> � + <br /> i <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado6e ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes X No ❑ 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) <br /> /0-0-------DistankDistance from nearest well__ <br /> jropri foundation_-_ r ateSe tic nria <br /> No. of "e f___ Liquid depth ~terPartments __ _-3------ -- -- Capacity <br /> acrity----fti Y� <br /> t=_.__ <br /> Disposal Fief: Distance from nearest well__/Q0-t---Distance from foundation---,1a__t_Distance to nearest lot line_________________ <br /> Number of lines___________ __ __ Length of each line________ ' � <br /> � � ------ - - g +�-°'1-�------.Width of trench----+�-------=---------------=-- <br /> Type of fitter material--� _ _Depth of filter material_-____/;L!/__-__Total length______ _ __ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---.-----------------Distance to nearest lot ine___-_____--_____- <br /> ❑ Number of pits----------------------Lining material-----------------------Size. Diameter-------------:---------Depth--------------------------------- <br /> p ;_ _ Distance from foundati ____ <br />� Cess ool: Distance <br /> titer nearest weEl :.r , ar _JQ_.Lining material____________________________________. <br /> ❑ ---------------Depth----------------------------=----------------t-- --Liquid Capacity----------------------------gals.�.I <br /> Privy: is+ance from nearest well__________-__________________________________Distance from nearest building------------------------------------------ <br /> El ;Distance to nearest lot line--------------- ----------------- ----------------------------•------------------------ --------------------------- .--------------- <br /> i <br /> Remodeling and/or repairing (describe)-----------------------------------------------------------------------­--------------- -•------••------------------------=-------------- <br /> -- ------------------------- <br /> -------------------------------------- ------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this app'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, Stag laws, an<Vrules and regulations f the San Joaquin Local Health District. <br /> (Signed) <br /> _-----.----------------- -- ---.---Owner and/or Con+rector l <br /> -------------- -- ------- -- -- --------------- Title---------------------------------------------------------------- <br /> (Plot plan, sho ng size of lot, iota+ion of-sys+em:in relation to,wells„buildings;etc,can be placed on reverse side).- <br /> q FOR DEPARTMENT USE ONLY v <br /> APPLICATION -CCEPTED BY:- ------------------------------------------- DATE-------- , r� <br /> REVIEWEDBY----,---------------------------------------- -----------------------------------------------=------------------------- ---- DATE----------- - ------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------=----------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterations and/0'e. recommendations:---------------------------------------------------------------------------------------------------------------------------•--------------•------------------ <br /> ------------------------------ <br /> ------- <br /> --------------------•--•-•--- -------• ----------------------------•-•-------•-------------------------------......._...-------------------------------------------•--•---------------------------------------------- t, <br /> ------------------------------------------------------------------------------------------- <br /> -------=------------------- --- -------------------------------------------- ---------------------------- -------------------------------•----------------------- - ---------------- <br /> FINAL INSPECTION B ______ _____ _ ______ --------- Date-.------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> I _ <br /> 130 South American Street' 300 West Oak Street 132 Sycamore Street 814 North "C” Sfreef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES---9-2M 8-51 Revised W-2100 <br />