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FOR OFFICE USE: <br /> ------------- ITATION PERMIT Permit No. <br /> --------- ------------- -- ------I-------- APPLICATION FOR SAN Duplicate) . <br />-------------- ---------------------- -- ------------ - (complete in Dupli ) _7 <br /> Date Issued <br /> ...... This Permit Expires I Year From Date issued <br />-------- -------------- ----------------------------- <br /> Application is hereby made to the Sar`' 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 /> lvt 0 <br /> JOBADDRESS AND LOCATION__,,��__J_22 ----------- -------------------------------------------------------------------------------------------------- <br /> Owner's Name----- --------------------------------------------------- -- - ---------------------------------- ----- Phone----------------------••------- <br /> Address <br /> hone-------------------------------Address----_------ ----- ---W VZY4 /,—-------- ------- --------------_-------------------------------------------------------------------------- <br /> Contractor's Name--- ------- ,P7- ----------------- ----------------- --------------------------------------- Phone------------------------------ <br /> Installation will serve: Residence 0Apartment House [I Commercial E] Trailer Court 0 Motel 0 Other <br /> Number of living units: __/_ Number of bedrooms A--- Number of baths Z---- Lot size ----------------------------- <br /> 40 ., <br /> Private ❑ Depth to Wafer Tab ft. <br /> Water Supply: Public. ^i E] le <br /> system [,Community system E] <br /> .1 <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Fj Sandy Loom E] Clay Loam El Clay El Adobe R?lHardpan ] <br /> Previous Application Made. (if yes,d9te--- ------ ---------) No 2"` New Construction: Yes E] No e- FHA/VA; Yes E] No g _ <br /> TYPE OF INSTALLATION AND.SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Distance from nearest well-----------------Distance from foundat�on_----z-----------Material-------------------------- ..................... <br /> No. of comparfmenfs--.-. __Size-------------------------- -----Liquid dep.fh--------- ---------------Capacity_____- ______._ __ <br /> 01 m I <br /> I nearest lot line--/ ---- <br /> Disposal Fielcl,� Distance from nearest well---- '_____-Distance from foundation-___ <br /> `__.___.Distance Distance to <br /> ---- ---------Width of trenck <br /> 7------------ <br /> Number of lines---I---- Length of each lire--;-- <br /> Type of filter maieri4q_-A-il Depfk of filter material_._.�w-----Ir...Total length_-_A;vw------------ <br /> well from fo nclation----le_�------Distance to nearest lot line-,--` <br /> ,epage Pit: Distance to nearest' -------- ._.__--_Distance f <br /> M_ Number of pits---.--/------------Lining material- ___.-,Q ---Size. Diameter- -- -------------Depthlz�I---------------- <br /> Cesspool: Distance from ne I arest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> I ---------------------Liquid Capacity. .....------------r-------gals. <br /> El Size: Diameter..- -------------- -- ----------------Depth---------------.---------------:-------------------------------- <br /> - <br /> Privy: Distance from n I e I arest well-------------------------------------------------Distance from nearest building----- <br /> Distance to near ---------------------------------- <br /> ❑ est lot line..- ---y- <br /> --- - -------------------------- <br /> ------------ <br /> - <br /> --------------------------------------------------------------------------------z---r--�------------------------------- -r �-- - ---- ----- <br /> Remodeling and/or repairing (desclibe):---------/K__ --- -- <br /> 1 --------------------- <br /> --- <br /> ------ --------------I----------------------------------- ---- <br /> ------------------------ <br /> -t <br /> --------__ - - - _. -- __ - - -------------------------------- ----------------------------------------------------------------- -------- - - <br /> [ hereby certify that ------ <br /> 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 /> - ---------jCm%eP-ettcVor Contractor) <br /> (Signed)---------------------- <br /> -�e -- --- ---- -----------------------------------------er <br /> ---------- <br /> ------------- <br /> --—------------ ------------- - ----------- <br /> By:------------------------------------------- ------------------ --- --- <br /> �e <br /> ;n off sysfe relation to wells, buildings, etc., can be placed on reverse side). <br /> (Plot plan, showing size of lot, locat�iot <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- DATE----------( --------- -- -- ------------------------- <br /> ------------- - -- --------------------------- --------------------------------------- I <br /> * <br /> REVIEWED BY---------------------------------- DATE _-.... <br /> BUILDINGISSUED--------- <br /> .................------------------- <br /> PERMITISSUED---------------[------------------------------------------------------------------------------- ----- DATE-------------------------------------------------------- <br /> _------------------------------------- <br /> Alterations and/or recommendations:----------------,I: - ---------------- - ---------------------------------------------------------------------------------- <br /> -------------------------- ---------------------------- ------------------------------------------------------ h-------------- - ----- <br /> --------------------- ------------------------------------------- ----------- -------- ------------------------------------­------------ -------------------------------------------------------------------------------; <br /> ,.I --------------------------------------- ------------------I-----------------­--------------------- --------------- <br /> -------------------------------- --------------------- ---------------------------------------- <br /> ----- -------- ­-------- ---------------------I--------- ----------- -------- -------------------------------------------------- -------------------------------------------------- ----------- <br /> ----------- <br /> Date_.. <br /> - ---------------- ------------ -------------- <br /> FINAL INSPECTION BY;------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street L <br /> Manteca,California Tracy,California <br /> Stockton,California Lodi,California <br />