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f' --------- <br /> -. APPLICATION F . NITATION PERMIT Permit No. ...f...... S ` <br /> ,• r <br /> -_---:_------ Y.:............- (Complete in Duplicate) <br /> Date Issued <br /> -----------_----------------­---_____________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Healfh 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 L CATION._.. b__ ----------c>«� <br /> ------ ---------------------------------------------- <br /> Owners Name ' --��'t-------- ------------------ -------------------- Phone <br /> Address -�- ] ----------------- ----------- ------------------------------------------- <br /> Contractor's Name......... -.._.il.. ...... Phone <br /> Installation will serve: Residence Q Apartment House ❑ Commercial ❑ Trailer Court g]-`Motel ❑ Other ❑ <br /> Number of living units: --- _ Number of bedrooms,.. Number of baths _Y.... Lot size _* -t -f___._.................. <br /> Water Supply: Public system ❑ Community system ❑ Private ®-Depth to Water Table __loft. / <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �rdpan ❑ <br /> Previous Application Made: (If yes,date-----------.........) No E]1_11�.New Construction: Yes [!]�No ❑ FHA/VA: Yes ❑ No� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> S <br /> Septic Tank: Distance from nearest well--.3.[_O._--Distance from foundation_/O-------------Material--- v _.__-..-._.-____-__. <br /> 2____ No. of compartments....a...............Size..=_ __a[_.3Z(.__.._.Liquid depth.___._.-.........._.Capacity._._.2.Si_,00-) <br /> Disposal Field: Distance from nearest well..,,.,f_.0....Distance from foundatiogft.0.{_....._.Distance to nearest lot <br /> ... <br /> Number of lines__________;X _...............Length of each line. .a.(7__!'_.._-___-___.Width of trench-. .. 'y <br /> Type of filter material.-7/?0_K......Depth of filter material-__:. Q'...-------Total length......... -o_!.......t--------------- <br /> Seepage Pit: Distance to nearest well —3,911 r.......Distance from foundation_/A........._..Distance to nearest lot line...St7. _._ <br /> Number of pits___..° --Lining material_2� ...Size: Diameter..--_ . ..........Depth........Z...., -_.-__:_.--- (n <br /> Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material--..___-----_-_-.----__-_-_.__-__-.-_. <br /> ❑ Size: Diameter--------------------------------------Depth--------------------- ----..-..------ -------------Liquid Capacity---- ............ ---------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------_-___-____--.....__---- <br /> ❑ Distance to nearest lot line.............................................. - ----------------------------------------•-------------------------------------------------- <br /> Remodeling and/or repairing (describe):. = ----------------------------- - -----------------------------------------------------;------.... I <br /> 7 <br /> -------------------------------------- ------------------------------ —•--�-----••--- -�L 1 ----------- <br /> I �•c.=c,�' � t� - "..5- / �� <br /> : X <br /> I hereby certify that have prepared this appliEation and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulaarela <br /> Joaquin Local Health District. <br /> - _.__..._ __ _ _ _ Owner and or Contractor(Signed)-----------•---••-------•------------------------- ------•- ---• -�---••---------------- ------- --- ------------------I / ) <br /> By:-------------------------------------=- - ------- --(Title)-_---------- ------------------------------- -- ---- --------- <br /> (Plo+..plan, showing size of lot, location o syo wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------yam,-'------- -- ......... r- DATE. Zf = / <br /> REVIEWEDBY----=-------------------------------------------------------------------------- - •----------------------------------------.- DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED............... — ----------....._.------ •--v----im-------.._.... DATE <br /> ._. .. ----- - <br /> Alterations and/or recommendations:. .. <br /> zt f- ---- ...........'.s .... = <br /> .-............ .. ... <br /> ..-------• - -DLJ. �' --- �.-.--= `� - = --------- <br /> ......... <br /> _..c ..i-- ....... ---------------------­ <br /> FINAL <br /> ----'{�----`- .`-_. <br /> FINAL INSPECTION BY:.... .... .. .... Date..------. ------- ------ -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> It <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 3M 3-'63 F.P.CD. <br /> s <br />