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2 -APPLICATION FOR SA RMT JPermit No. A -IV <br /> ,!i <br /> -------------------- <br /> Iq (Complete - icatel <br /> Date Issue/d <br /> �plicafion is hereby made to/the San Joaquin Local He o construct and install the work herein described. <br /> is <br /> application is Made incompliance with County 0 manceN'6­54- <br /> --- ----- - -----------------t----------------------------------------I---------------------- <br /> JOB ADDRESS AN . -LOCA N________.__ -- -- ------- <br /> Owner's Name---- --------- -- - - ----------------- - -------------------------------------------- Phone...... <br /> Address-- <br /> ------------------------------------------------------------------------------------------------ <br /> Confracfor's Name ...... <br /> I------------------------------------------------------------------ Phone... <br /> ----- <br /> ------------------- <br /> Installation will serve: Residence Apartment House [j Commercial,E] Trailer Court L] Motel [] Other Ej <br /> Number of living units: ----- Number of bedrooms Number of baths /---- Lot size _,Ar,2-_fPt_4_----------------------- <br /> Water,Supply: Public system E] Community system El Private Depth to Water Ta61-­/,0 ft. <br /> Character of soil to a depth of 3 feet: Sand 0 Gravel 0 Sandy Loam Ej Clay Loam E] Clay E] Adob <br /> _jr Hardpan El <br /> Previous Application Made: Yes Ej No New Construction: 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 Tank: Distance from nearest well_-_______-----_Distance from foundaf;on------------------_Material------------------------------------------------- <br /> No. of compartments------_ -_Size--------------------------------Liquid depth--------------- ----------Capacity--------------------- <br /> /V -Di._Distance <br /> --- <br /> 4q tp� illisF64 Field, Distance from nearest welfrom foundation_ _/69 Distance to nearest lot line----- -------- <br /> Number 0.1 lines-------/------- --------- - ---Length of each line--------- -7V -----Width of trench- <br /> ---------------- <br /> II Type of filter material - ----- - ------Depth of filter materal----- ---------Total- length------------ -------------------- <br /> ]el- <br /> Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest ]of line-___-_____-----_ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------- ---------Depth_------------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---.--_-___------.-_.------_ ._..___. <br /> ❑ Size: <br /> aterial-------- -------- --------------- <br /> Size. Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------- -------------------- <br /> -"'-Distance from nearest building_-__-_----.__._____..__________-________-, <br /> --V' <br /> ❑ <br /> Disfance to nearest lot line-----------------------------s--_-___--__- ---------------- <br /> ------------ <br /> ------------------------------------- <br /> Remodeling and/or desc -4 <br /> repairing xibe):__ - - -------------------------------------------------------- <br /> ------------------•------------------•------ ------ -------- --------------------------------------------------------------------I---------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I------- <br /> -------------------------------------------------I----------------------------------------------__...I-------------------------------- --------------------------------------------------------------------------_------- <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 s, and les nd regulations of the San- Joaquin Local Health District. <br /> (Signed).......... <br /> --- - -'---r -- ------ --------------- ----------------------------------------------------------------------------- ---(Owner andjor Contractor) <br /> B :_------------- ------------------------------------------------' •--------------------------------(Title------ .... ..__W__1_Is- -- ------ - <br /> (Plot plan, showing of---lot,- 2ic ation of system in relation to wells, buildings, etc., can be P! on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__(� - --- --------------------------------------------------------- -------------------- DATE_ O <br /> __I;a�---------------------------------------------------- <br /> REVIEWED BY------------------------------- <br /> - --- -- ------------------------------------ I- ---- --------------------------------- DATE-- 5F-------------- <br /> BUILDING PERMIT ISSUED ........ -------------------------1-------------------------------------------------------- DATE---E--- <br /> ,. . ;`:il--------------------------- <br /> Alterations and/or reco m mend afions;---------------------------------- ------------------------------------------------------------------------------ . Im ... <br /> --------------------I------------- <br /> -----------------------------I--------------------------------------------------w------------------------------------------•---------------------------------- ------------------3<--•-----------•------------�- <br /> --------------------------------------------------- I---------------------------------------------------------------------------------------------------------------------------­-------------; --------------- <br /> 1 71 . <br /> ---------- -------- <br /> --------------------­------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------- <br /> T-------------------------- <br /> -------------------------------------------------------------------------------- <br /> -- --- -------- ----------------------------------------------------------------------------- ---------------------- -------- <br /> FINAL INSPECTION BY-------------- - Z� <br /> ---------- ------------ Date------_---------- ---- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manfeca,'California Tracy, California <br /> ES-9-2M 10-52 Revised W-2104 <br />