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1 .F0RvOFFICE USE: APPLICATION FOR MITA'flON PERMIT <br /> ------�------ ------ ---=--------•- i Permit No. --:_ <br /> (Complete in Triplicate) <br /> _ - - -_ ---- This Permit Expires 1 Year From Date Issued Date Issued <br /> _ __ _ _ <br /> i! <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> f ` <br /> JOB ADDRESS/LOCATION/��'lf-_N--_vt _1a�u.,s C- BN___ l.__41de_--_- e--- CENSUS TRACT �Y ��-._.... <br /> -- ------------ <br /> Owner's Name ----- `�r91 =-�_`?c -----------------_--------------------------------- <br /> _ Phone - Z <br /> Address ------- -----„S• ---------------------------- Cit / --- ll --------------------------------------------- <br /> Contractor's <br /> ------- -------------------Contractor`s Name ---- 4----11-�n -----------------License --- Phone <br /> Installation will serve: Residence Pl!(P�artment House❑ Commercial :E]Trailer Court ❑ <br /> Motel ❑ Other ----- -------------------------------------- <br /> Number of living units:-"--_f------ Number of bedrooms - --_-Garbage Grinder ------------ Lot Size --------- __J-------14q_,�,------._-- <br /> Water Supply: Public System and name ---- ----------------------------•------------------- --------------------------------------------------------Private [t�� <br /> Character of soil to a depth of 3 feet: Sand' ilt C] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> .. .. _ - :: . - - ��Hardpan ❑ .Adobe'C]� Fill Material_ �r 1fmYes-type --------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK' - -Size----/--- -- Liquid Depth --- ----------- <br /> r� <br /> Capacity - Typ CC�i/____ Material��°�� _ No, Compartments -----------.- <br /> Distance to nearest: Well --------------------Foundation -_J ------------- Prop. tine ---`2--C_-_-_-_-___ <br /> LEACHING LINE [ j No. of Lines -tR------------------- Length of each line"----1- ----------------- Total Length : _--- <br /> --IS- -------------- <br /> D' Box --�,-____-- Type Filter Material m _±-__Depth Filter Material ------1-9--------------------------------- <br /> Distance to,nearest: Well _S__0-------------- Foundation <br /> -------------- Property Line. ............. <br /> SEEPAGE PIT [ ] Depth _ Diameter ---------------- Number ------------------- Rock filled Yes ❑ 'No 10 <br /> Water Table Depth { --:-_- --. --Rock Size "- •-�-� <br /> Distance to :nearest: Well -------=--------------------------------Foundation ------------------=- Prop. Line ------------_-_------- <br /> I 1 <br /> REPAIR/ADDITION(Prev. Sanitation 'Permit# -------------------------------------------- Date -------------------------------t--) <br /> Septic Tank (Specify Requirements) -------- ---------- ------i------------------------------------------------------------------------ - <br /> --------- ---r---------------------•------ <br /> Disposal Field {Specify Requirements) ------------------- j _---_--_-_-- <br /> ------"------------------------------------------------ ----------------------------------------------------- ----------- ----------------------------- ----------------------------------------- <br /> I <br /> �,•, - ------------ - --- <br /> - --- - ------------- - -- -------- - -------- --- - ------- ---- - -- - - - - - - - - ------------------ <br /> (Draw exisfi"rig and required addition-'on`reverse-side}� "- <br /> I 1 herebycertifythat I have prepared this application and that the work will be done in accordance 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: _..-•-—- . i i <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 /> g Compensation laws of California."as to beccomf subject to Wor n's' ` <br /> Signed -KJ I' - - _ <br /> -- ------ ------- ---------------- Owner <br /> BY �^9 --_4 --lrf' � Title ---------------------------- <br /> (If other than owner) - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _..---1--Jj_-.0-------- F --A f'45E11(----- ---- ---------------------------- DATE <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------- ----------------DATE ------------------------ <br /> ADDITIONAL COMMENTS ---- --- - ------------ ----- --- -- -- ---------------------- --------------------------- <br /> ---i <br /> ----------- - -- --- ----- ------------------------------------------------------------------------------------------------------------- <br /> - <br /> ---- - ---- -------------------------- ---------------- ---- ---------------- <br /> Final <br /> Inspects - - - - --- - - -- --------------------­------------------------------Date -_� --�-� - -- ---- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />