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FOR OFFICE USE: <br /> --------------- ------------------------------------- <br /> APPLICATION FC, . 4TION PERMIT Permit No.,�.� <br /> ---------- ------ - ------ --------- ---------- (Complete in Duplicate) <br /> .................. This Permit Expires 1 Year From Date Issued Date Issued ___-_------.___---..___ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is made in compliance_ with County Ordinance No. 549. 0(P3—l.ct <br /> JOB ADDRESS AND LOCATON--;---fP-1/;?P­/__�--, <---z7x---bV-.-_.QCI_---AIA-X .�dZ--6K--_-tib -j1/1�/�--- a,-----_------ 1 <br /> Owner's Name_________ 77 <br /> 1�.�_--�----- 're-4-��k-�-�__..------ - _ Phone------------------------------------ <br /> Add <br /> ---- --------------------•------- <br /> Address -------------------------------- <br /> Contractor's Name--------- 1 �� r----------------------------- - Phone...-----------•------------------- <br /> Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑g)Other ❑ <br /> Number of living units: J--- Number of bedrooms___ Number of baths P-_ Lot size` -XA6?'________________.__.__ I <br /> Water Supply: Public system ❑ Community system ❑ Private 2�' bepth to Water Table 4�f`ft. <br /> k <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe &'Hardpan ❑ <br /> Previous Application Made: (If yes,ldate-----------_--------) No ®" New Construction: Yes [jR'No ❑ FHA/VA: Yes [l- No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sever is available within 200 feet.) <br /> A <br /> Septic Tank: Distance from nearest well__�0__ Distance wrgm foodatio�n�_�Q______._.Matt rial__� .�C� ---------- <br /> No. of compartments_._-F-----------------Size_ttk`7iquid depth__�___._._.__....__Capacity�.`_�__�__.___ <br /> Disposal Field: Distance from nearest well.610-7__-__Distance from foundation----...__.__Distance to nearest lot line_/Q__.______ <br /> 99— Number of lines------,►__ Length of each line`�____ Width of trench- - --------------------------� r <br /> Type of filter material_-� �Depth of filter material-l��---.Total length_ i�� <br /> Seepage Pit: Distance to nearest well..1690 r-Distance from fo ndation__ea-________-Dist oce to nearest lot lir%`Q_---__ <br /> 0� Number of pits­,9- Lining material��-_Size: Diameter,-_...._._.___Depthp?t�_.___.__._______.._, <br /> Cesspool: Distance from nearest•weld-----------------Distance from foundation-------------------- Lining material--------------..---------.--_-___.___ <br /> ❑ Size: Diameter---------------------------- ---------Depth---------------------------------------------------._Liquid Capacity --------- ------•--gals..-_-,k+ <br /> Privy: Distance from nearesf well-'--....__.;---------------_._. -Distance from nearest' building______________________-____-______._ � I <br /> ❑ Distance to nearest lot line------- - ------- ----------------------------------------------------------- ------------------------------------------------------------ A <br /> Remodeling and/or repairing (describe)----- - - � ---------•----------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------ <br /> 1 <br /> _________________________________ _______________________________________________________________________________________________________________________________________________________________._____,_..,_.__ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules an regulations of the San Joaquin Local Health District. <br /> (Signed) r Contractor <br /> ------ - --- <br /> ;�uBy:_______________________________________________________________________________ ._____Title _ <br /> (Plot plan, showing size of lot, location of system in re on to wells, buildings, etc., can be placed on reverse side). ' <br /> FOR DEPARTMENT USE ON Y / <br /> APPLICATION ACCEPTED BY----------------------------------------------------- ----------- �� i/- DATE-------- , <br /> REVIEWEDBY------------------------------------------------------------------ -------------------------------------I ------------------ DATE------------------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE--------------------------- ------------------ -------------- <br /> Alterations and/or recommendations:----------------------------------------------- --------------------------------------------------------------------------------------------------------------- <br /> ---------- ------ ---------------•- ----------- -------------- -.----------------------------------- {1 <br /> -----------------------------------------------------•-------------- ------ ---------•----------------------•----------------------------------------------------------------- -------------------------------------------- f <br /> FINAL INSPECTION BY:..... �7�A�/ /I Date__ ----.,;7------ ....................... ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ' I' <br />