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FOR OFFICE USE: -*'NITATIOW PERMIT <br /> APPLICATION FOk�ISA <br /> --------------------- -------------------------- <br /> Permit No. <br /> '(Ccim�P10i 16 Triplicate}e) <br /> .......... ------'---------------------------------------- <br /> -----7---------------------------------------- <br /> Date Issued 0--7 Z,` <br /> ----------------------------------------- --------------- This Permit Expires I Year From Date Issued ----- --------- <br /> 7 <br /> Application is hereby made_tthe San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is mdde in compliance with County Ordinance No. 549 and existing Rules and Regulations.. <br /> JOB ADDRESS/LOCATION <br /> e2v 7 2LI_ �_s-------- ------- -,c------------------- ------------------------CENSUS TRACT --------------------_--- <br /> 2 Owner's Name ------ ---------------------------------------------------------- -------------Phone <br /> Address ---- ------------ ---------- ------------------City wwee�1_24Z------------------ <br /> ------ --------------- <br /> Contractor's Name . . ....... 2-zexer, j:�r Phone �J <br /> Installation will serve: Residence---W"c-'Ap-artm-ent-House-[:]-Com'merciaI❑Trailer Court :E3 <br /> MotelF-1 Other -------------------------------------------- <br /> Number of living units:_/---- Numl5er of bedrooms ______Garbage Grinder ------------ Lot Size ------KZc --______________ <br /> Wat6r Supply: Public System and name ---------------------------------------------------------------------------- -----------------------------------Private 71r. <br /> _.� .1 f Alai <br /> Character of soil to a depth of 3 feet: Sandy' Silt E] Clay [] Peat[] Sandy Loam ❑ Clay Loam E] <br /> Hardpan C] Aclobe,E] Fill Material ------------ If yes, type ------------ --------------- <br /> A <br /> (Plot 1plan, showing size of lot, location of system in relation to wells, buildings, etc. must be.placed on reverse side.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avoildi5li;wZthin200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size--A4 Z rO___Y---41_Y - ----- Liquid 'Depth ---- ........ <br /> No. Compartments ---- <br /> o�-Ty�e 1----------- I--- IV _L�777�. 7-e- m�---------- <br /> Capacity Material-i a <br /> Distance to nearest: Well -- ------ --------_--------Foundation --- ------------- Prop. Line ............ <br /> LEACHING LINE (1-r;1'­No. of Lines -'---',LengtK of each line-------2_�----------- Total Length .____ s_ -_---__________ <br /> I? I <br /> -Type Filter-Material ___f�A-�Z_Chepth Filter Material ____________________ ___ <br /> Distance to nearest: ------- Foundation ---------------------- - Property Line ....... <br /> SEEPAGE PIT Depth .___Al_______-__ Diameter Ck ------ Number ------7—----------------- Rock Filled Yes E?-- "No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ----------------------------------------Foundation -------------------%-Prop. Line ....... .............. <br /> REPAIR/ADDITION(Prev. Sanitation Perrnit# -------------- ------------------ ----- ---- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------- -------------- ------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------- ---------- --------------------- ----------------- <br /> ---------------------------------------------------------------------------------------------------------------------- -------_------------------------------------------------- ------------------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------------------------------------------------------------------- Owner <br /> By ----------------------------- Title-------------------- <br /> (!f <br /> itle ------------------------------------------------- ---------------------- <br /> er th wrier) <br /> (If othr;i; �Ov------------------------------ <br /> FOlt DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ 6Fcr---- ­ DATE ----- <br /> ­-------------------------------------------------------------- <br /> - ------------- --------- ------- <br /> BUILDING PERMIT ISSUED ------ ------- ZI1- DATE <br /> ------ <br /> -----------: <br /> ADDITIONAL COMMENTS ........ -- <br /> ------ --------------------------------------- --------------------------------------- . <br /> ---------------------------------- -- ---------------- ----------- ---------------------- <br /> ----------------------- ----------------- --------------------------------------------------------------------------- <br /> Final Inspection b ------------------- --- --------------------------- ------------------------------------------------- <br /> Y: -Date ------- ------------- <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />