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APPLICATION ��� �����T�� P���[� Permit <br /> Z, ~��/ ^ _ <br /> � (Complete in Dup|imate) ' <br /> Date |muo6 � <br /> � . � <br /> is <br /> 6 �n�nUf6�wor herein 6 ��n6 <br /> 6o� y made � �e S� ��| Health District for u �m� to construct an �� m mz . <br /> This application is made in compliance with County Ordinance No. 549. � <br /> ------------- <br /> Owner's '��"��� <br />� ' <br />' �ddnes-__ '--_--''---''-----------''--'--''--''--'-' ~ <br /> ��� ----------- <br /> Contractor's Mume --_.^~^�'^�^��-'°�c'��-+^�----.,.-- + ---_ <br />/ --------- <br /> Installation will men~n- Residence Apartment House 0Commen`iu| E] Trailer Court E] Motel 0 Other E] <br />� Number of living units: umber of bedrooms I--- Number of baths J-_~.. Lot size ------------------------------ <br /> Water <br /> ----_-_--.-.Vata ' <br /> Supply: Public system Community system [I Private [-1 Depth to WatorTa6|o~&- ft / <br /> Chmnau+a, of <br /> ' soil to a depth of <br /> '3 feet: Sand [] Gravel [] Sandy Loam [] Clay Loam E3 Clay E] /\6o6e 0M Hardpan [] <br /> U Made: Y �� N [� N Construction: Y [� N <br /> Pro"|omm Application o �� u, ym� o v� n, u <br />, TYPE OF INSTALLATION AND SPECIFICATIONS- ^: � <br /> (No septic tank or cesspool penn|fta6 if public sewer isavailable within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Ma+erioL,-------.---.----_- <br /> � El No ofcompartments---------------------------Size---------------------------------Liquid depth--------------------------Capacity------------------------ <br /> Disposal Field: Distance from nearest well.- --------- ._Distance from foundation---------------------Distance to nearest lot line----------------- <br /> th of <br /> / 0 Number- of lines- - <br /> �C Type offilter <br /> -material -'''---�'''Dop+ of filter material 7oto| | �oth' <br /> '__--_---_.-�--_.. <br /> ~~~'age �f' Distance to '- - m/ d 4r-�-_Di�ancu to neams+ lot |in�. --- _- <br /> Number of .LiingDiameter <br /> ` u| �e� D�m°+ c.' ..........Dvo+�' --'---- <br /> Ce, poo|: Distance from nearest weL--_-Dktuncofn,m {pun6n�on-'_---_.�ninq muto,�L-_-'-_--.__'_ <br /> �� Size: Diame+ec._----�--��--. -------------- -.-�_--_'-_..Liqu|6 Capacity---------------------------gals. <br /> ^ '",y' Distance from nearest well --------------------------------------------Distanm, from nearest building._-----____--' <br /> [1 g� <br /> Distance fn neun*� lot |�°.'`--''----__°.'-'-��'-�.--'`-~~-''''--��----''''-'-------------------- <br /> Remodeling and/or 'repairing /des&iloe)-- _. <br /> '---'--''-----'------------- <br /> ' - -'-~�-~---'--7�� ------------`�������� �� <br /> -'------'-------'---------'-----'-------'---'----'--'--'-r�--'''~'''---'------'�------ <br /> . <br /> ����---'---------___------'------------------'_---------_-------------_---------'----------'-------­--__------'--------------------_------__---------------_--------------'---_------'---_���'--- <br /> I hereby certify that I have prepared/t" application and that the,work will 6e6 inmcco,6 n'cowith San Joaquin County <br /> ordinances, State ws, and rules and regula ons of the San Joaquin Local Health District. <br /> -/-v i_j------(Oywn , and/ r) <br /> (Signed)------------ - - ---------9 pr Contracto' <br /> --------------------- <br /> t (Plot plan, showing size of lot, location of system in lafion to wells, buildings, efc., can be pla��d�,n reverse side). <br /> FOR DEr*n/xoEm/ USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY------------------ ------- DATE------------�V_ <br /> BUILDING PERMIT |36UED'---.__--_-__l_-..��_'_-__--__-.�' uA/�-.__---._-___-____ <br /> , <br /> ----' - -' ' .~r' ^ .*�. <br /> AKerm+�nsanJ/or ,ecommonda�ons�-----_--_-___.^^^-..___----__--_-_ ,___--___----------- _____ <br /> ' _-�-_.'-�----__-�_.__�-��.���--��---._��..�-���--.__--__-_�'_--��--�-__-'�_.___.-__ <br /> -'-_--_--_.'--__''--_---'''-�'''-_-'--,_-'''-^'-_---''-_-'--`--_''--_-''-''''---_--.-'_-.-__'�'- <br /> ' ---'--'------''--'------------'---'--------'--'-----'-------------------'-----' <br /> -~' ____'-_- <br /> ''-'/-''--''-���-- '' .-'�_''_--''_-''-�-_-'-'''-' <br /> RN�L |N�PR�T|{}N BY�' Du+e-�^ ��� -_�� --'--.'_---'' <br /> SANJOAQUiNLOCAL HEALTH DISTRICT <br /> ou s"mk American Street sooWest Oak Street /xisvc°="re Street ow North "C" Street <br /> ^ m"vkfm". Co|nornm Lodi, California w"",°"°. o°|n","i" Tracy, California <br /> , <br /> ss-9-2w 8-5/ Revised vv-2/00 <br />