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FOR OFFICE USE: <br /> k.,. �� <br /> --------------------------------------------------------- <br /> APPLICATION FOR,& �NITATION PERMIT Perm' o. _- ...7`.9 <br /> t (Complete in Duplicate) 7 <br /> fThis Permit Expires 1 Year From Date Issued Date issued ______/ ------ <br /> Application <br /> G 7i <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 /> JOB ADDRESS AND LOCATION._ / ° ---_-------_-_ <br /> Owner's Name---- <br /> -f- <br /> ame e -----•------ ------------------------------------------------------------ Phone.................. -• -•---------- <br /> ---... <br /> I Contractor's Name_- ] <br /> Phone.. <br /> Insfallafion will serve: Res'8lence,0 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 W Depth to Water Table-;- ft. <br /> Character of soil to a depth of 3 feet: Sand p Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> 4 <br /> Previous Application Made: llf yes,date--------------------I No New Construction: Yes W No E] FHA/VA: Yes El No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> i (No septic tank or cesspool-pt rmitted­if-public sewer is available within 200 feet.) <br /> I ai, 1 <br /> Septic Tank: Distance from nearest well_- - Distance from foundation-/J2--'-----------.Material... ....................... <br /> [� No. of compartments-.---------- -------Size-- - •-- .......Liquid depfih----44------------------Capacity..?U_V........ <br /> t <br /> Disposal Field: Distance from nearest well__S-Dr.........Distance from foundation_-.-St------------Distance to nearest lot line__$-------- <br /> Number of lines- -_�___- _-+=---- Length of each line-------Lz-----------------Width of trench---3.14.t---------------------- <br /> Type <br /> •-••--.---_----_----- <br /> T e of filter material .-_De th of filter material--- ' --------Total length----A-0------------------------------- <br /> Seepage Pit: Distance to nearest well---e!- __--------__.__-Distance from foundation....................Distance to nearest lot line---__---.-__----_ <br /> ❑ Number of pits-----------2'0__Lining material-----------------------Size: Diameter------------------------Depth----..-._._---------..------_---- <br /> Cesspool: Distance from nearest swell-----------------Distance from foundation-------------------Lining material-----------------------------....... <br /> ❑ Size: Diameter.---' -------------------------Depth-------•-------------------------------------------.Liquid Capacity---...............------....gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building.----_..-_-------_----.-------.......-.... <br /> ❑ Distance to nearest clot line----------------------------------------------- ---------------------------------------------•--••--•-----•----------------------------------- <br /> Remodeling and/or repairing (describe):_!----------••---------------------------------------- ............. --------------------.--------------------------------------t <br />' ---•--------------•----------------------------•-----..-. --------------•----•--------•--------------------------------------•-------------------------------•----•-•-•---.--.-----------------•-•------- <br /> t <br /> 1 hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws`,f <br /> atO,rules and regulations the San Joaquin Local Health District. <br /> (signed)----- --------------- -----------------------s-------- --------------��:�":��---�----------------------------------------------------(Owner end/or Contractor) <br /> -� BY= = === ===== ------------------------------------------------------- - = ------------------ <br /> ----_-- = - ------ <br /> (Flat plan, swing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side]. <br /> FOR DEPARTMENT USE ONLY <br /> of <br /> APPLICATION ACCEPTED BY ----------------------_----------•----------------------- DATE-----' --------------------------- <br /> REVIEWEDBY-------------------------------------i-----------------------------------------------------------------------••-------------- DATE <br /> BUILDINGPERMIT ISSUED----------------f--------------------------------------------—----------•--------------------------- DATE------------------------------------------------------------- <br /> -- <br /> Alterations and/or recommendations:;-- ------ ------- ------- -- <br /> --------------------------•--------------------------------------- <br /> -------•-----_.------------------- - <br /> ---------------------------------------------------------------- --------------------- <br /> ------•--•---------•---------•-------------------------------------------- --- ------------------------------- ----------------------------------------------------------------------------------- ------------------­------- <br /> Date--- <br /> FINAL INSPECTION BY:- ; - Y. _. <br /> e <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 REVISEo 6-59 2M 5-61 ATLAS <br /> i <br />