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FOR OFFICE= USE: <br /> l� a APPLICATION FOR S�k�I17A'I"lOi�l PERMIT <br /> ..j._. 7 7- iarY <br /> (Complete in Triplicate) Permit No. ..................... <br /> ` d _.-gip_:�7 <br /> __.___._... This Permit Expires � Year From Date Issued Date Issue - • •••. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. ....... <br /> -_ _ �......, ...... .. <br /> CENSUS TRACT <br /> Owner's Name ......................:. ........ ..................... T <br /> Phone .................................. <br /> Addressy" City <br /> ..... .............•--•••--.._..-- --....._....---•-•-----....__.......----"... <br /> Contractor's Name _..._.... .. <br /> r �y/ <br /> �� • . -- ............. -------------License # p��(/l Phone. .. ..... ... <br /> Installation will serve: Residence U�Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ...................... <br /> Number of .living.units:...._. __. Number of.bedrooms ...3.....Garbage Grinder .-_--______- Lot Size .._. �:�� <br /> ..., _ <br /> " . • ................... <br /> Water Supply: Public System and name .................... ----------Private 0 <br /> Character of soil to a depth of 3 feet: Sand❑ , Silt❑ Clay ❑ Peat LD Sandy loom ❑ Clay Loam-D <br /> Hardpan ❑ Adobe-❑- NII IUlaterial - ------ If yes,type -------................... <br /> (Plot plan, showing size of lot, location.of system in relation to wells, buildings, etc. must be placed on reverse side.)r I <br /> NEW INSTALLATION: ' (No septic tank or seepage.pit:permitted if public sewer is available within 200"feet,) J <br /> PACKAGE TREATMENT SEPTIC TANK � "' <br /> j j . Liquid Depth ..---•-:............ O <br /> Capacity r----------- --•-- Type ........... •.... Material--------._.,._ ...... Na. Compartments . � <br /> Distance to nearest: Well ...-•.---------•......-..--•-••.----Foundation -:-------..... Prop Line ................. <br /> LEACHING LINE ( j No. of Lines .._...--r---- Length df each fine.............' <br /> Total Length <br /> ....... <br /> D' Box Type Filter Material __Depth Filter Material" ............ '"........... <br /> DistanceFto='rsearest:Well ' Foundation Property line <br /> �. s� ........... <br /> tic_.. .... <br /> [ ] Depth meter .... Number ..._. ..`..........•--•- .Ro Filled Yes-[5K,­,No.,0 <br /> --- ........ •- <br /> W to er Table De r- Rork Size .......: <br /> Distance to nearest: Well ----------=-----' .._ a` <br /> Found <br /> tion _;.................. Prop Line <br /> REPAIR/ADDITION(Prev. Sonitation,Permit# ....................-......,................. 'Date, ..................................� <br /> Septic Tank (Specify Requirements) ................................................................_....•---•...:..............._,.........._._. <br /> -.......... <br /> Disposal Field (Specify Requirements) -------------- -•------•• ..................... ----------.......... <br /> ------------- <br /> w.. <br /> .......................... <br /> .- " --fYprepared this application and thatthe k will bin actor. .--"""""".•.""""-"" (Draw required <br /> side) <br /> , ..•'---""-'-•--•••"•" -• -- <br /> ".-""'_•- <br /> I hereby cern that I have dance with.San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San 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 Corqpensation laws of Califo Ea." <br /> Signed _ <br /> •------ Mi <br /> _......- -• OwnerBy .... •.......... ----- -• , tleTi th now er). µ 1 <br /> FOR <br /> 6 OR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY 7.,.R ....,E! ... 119 -........... ............. •.....-----.... .......DATE ....F�.: �:`. .......... , <br /> BUILDINGP RMIT ISSUED ............. .......................•....................................................................DATE _.... ...................... ••-••-------" <br /> ADDITION L COMMENTS ...... ... ...................... ................................. ............ <br /> ._ <br /> ....----•-- .. <br /> ............. .."................. ._............ ._...._...-- .--......_-••---•..............._.._._ ` <br /> -�.................................................I..._..--•- <br /> FinaE Inspectio .. ............. � _ ..........•........ <br /> SAN JOAQUIN LOCAL HEALTH_DISTRICT <br /> E. H.13 241-'68 Rev. 5M _ u�` <br />