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FOR OFF <br /> -Zs !,CE USE; <br /> 3 <br /> 3 - ------------- <br /> �- <br /> - - <br /> 6 ��/E� <br /> ------------------------------------------- ----------- - APPLI(.:ATION FOR AR1 ATr" N PVERMIT ON Permit No. --....I................. <br /> 1CompJ�fa•in Duplicate) �t- �' f <br /> __ This Permit fxpire-s 1 Year From Date Issued �� Date Issued <br /> 4 / l� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work rein described. <br /> This application is made in compliance with County Ordinance No, 5499, <br /> JOB ADDRESS AND,.,OCATION------- /sem 1�C1� .T L. P---------------------- ------------- <br /> Owner's Name--------- ----------o-�j------ e•S'----------------------------- ----- -- ----------------------------------------- Phone --------- <br /> Address----------------a,1 ----- (/ ��1 <br /> Contractor's Name------ -Is— ------ Phone.----- ---•-----•------- <br /> Installation will serve: Residence P partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J--- Number of bedrooms - Number of baths---/--- Lot size ----- -I -�(1. -�._-X. ------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ------ - ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayAdobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date------------------- l No ❑ 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 /> Septic T Distance from nearest well-----------------Distance from foundation--------------------Material ----------------------------.-----.-------__.., 4 <br /> No. of compartments. ------ - -- - ----Size---------- --------- -----------Liquid depth--------- --- - --... Capacity---------------------- <br /> Disposal field: 4 Distance from nearest well___$'a`...___._Mstance from foundation-_��_.--......Distance to nearest lot line----�------ <br /> Number of lines .-.- -- Len th of each line-. -- �' <br /> ��i� I----------------- 9 �.� Width of trench.---------Z�� ------------- <br /> Type of filter material--s" 4---- --D th o alter material_._. . _-----_-_.Total length----_---�v---------__-------------- <br /> Seepage i Distance to nearest well------$'CY------- ;stance from f9pn ation----1- ----------Distance to nearest lot Iine__.Zd ---- <br /> �Z. Size: Diameter-- " r <br /> Number of pits --------------Lining materia - 3 --_--..--__Depth_.-...art .-- m,Y---l/t <br /> Cesspool: Distance from nearest well ----------------Distance from foundation___- - --- - - - --- _Lining material----------------------------------- <br /> El Size: Diameter- -- -- -------- -- - --- ----- --- Depth------ --------- -----------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest weEl___----------------------------------------_.....Distance from nearest building....----- ___.----._----- <br /> ❑ Distance to nearest lot line------------ ------------------- - --------------------------------------------------------- <br /> F <br /> Remodeling and/or repairing {describe]: //✓� . -- ----- r� �4 -------------------•-------------------------------------------------------- <br /> -------------------------------------------------------------•----------------- --------------------------------------- -------------- ----- ----------------------------------------------------------------------------- <br /> ----------------- ------- -------------------------------- ------------------------------------ --------------------------------•----------- --r--------------------------------- ------------------------------ <br /> I hereby certify that 1 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 /> (Signed) --------------------------- ------------ -------------------------------------------------------------- <br /> - <br /> ----------- -- -- -•------------------------------------- <br /> 9 )---- - - -- - - - (Owner and/or Contractor) <br /> I3 ---• --- ' ----------------------------- --- ------(Title)---------- ------ - - ---------- -... ------- ------- <br /> (Plot pla , s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- ` ---- -- ------------------------------ - --- ------ DATE----- <br /> REVIEWEDBY-------------------------------------------- ------------------- ----------------------------------------- - ------ --------- DATE---------------------- <br /> ------------------------------------ <br /> BUILDING <br /> -----------------------BUILDING PERMIT ISSUED-------- -- --------------------- ------.-------------------- DATE---------------- <br /> Alterations and/or recommendations:-- ' - -/-'-;-, .6. <br /> ------------------------------ <br /> ------ <br /> -------------------------------------- ----------- ....-- %-� - � .-�: ----- <br /> .. <br /> FINAL INSPECTION BY:. 119 00 ----------------- ----------. Date....._..37— - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi California Manteca,California <br /> Tracy,California <br /> E.H.9 2M I-67 Vanguprp'press <br />