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FOR OFFICE USE: APPLICATION FOR tAWrAnON PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ------------- ---------------------------------------- <br /> Date Issued _1Z ------------ <br /> ---------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Heblth 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 Re4ulationit <br /> ------------ ----------- <br /> TION -------IJ69 3....1� -----CENSUS TRACT ___________ - <br /> ADDRESS/LOCA <br /> 4 <br /> ---------------Phone ------------------------------------ <br /> Oppors, Name -------------- ---------------------------------------------------------- <br /> ------------------------------------------- <br /> ------ -----------------------------------•------------w City --------------------------------- <br /> Phone ------------------------------ <br /> CoMtrqct64r's4bme --------------------t�----- ---------------------- ----------------------License # ------------------------ <br /> -r Court E] <br /> Installation will sbrve: Residence P-Kpartment Housef:] Commercial E]TrailL <br /> Motel []Other -------------- <br /> -------------_";- --------------- <br /> It&nder ------------ Lot Size -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ___________Garbo L <br /> �g�.: <br /> Water Supply:-Public System and name --------------------------- ------------------------------I--------------------------------------------Private <br /> ❑ <br /> Character of soil to a depth of 3 feet. Sand'El Silt El e Clay E] Peat❑ Sandy Loom El Clay Loam E] <br /> Hardpan,E] Adobe r-1 Fill Material --------- -- If yes,type ---------------I------------ <br /> JPlot plan, showing size of lot, location of system in relation to wells,,'6buildings, etc., rDust be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank,or seepage'Pit permitted if pubfic.Tsewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK![ Size------------------4'•;- -------------------------- Liquid Depth ----------------__------ <br /> .........- -- ---- Mater <br /> Capacity -------------------- Type . ial---------------------- No. Compartments ---------- ----------- <br /> Distance to nearest: Well -_ ____.______--------------------Foundation ---------------------- Prop. Line ------------------------ <br /> LEACHING LINE I No. of Lines ------------------------ Length of each line___________________________ Total Length -----------------_--------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation- ------------------------ Prope4ty Line .----------------------- <br /> SEEPAGE PIT Depth ------------------------- Diameter ---------------- Number -.*------------I------------ Rock Filled Yes E] No Cc) <br /> WaterTable Depth -------------------------------------------- ---Rock Size -------------------------------- <br /> Distance to nearest.- Well ----------------------------------------Foundation -------------------- Prop. Line ------------------_-- <br /> REPAIR/AbDITION(Prev. Sanitation Permit# --------------------- ------------ Datei, -------------------------- <br /> ----------------------------------------------------------- <br /> Septic"Tqnk (Specify Requirements) ------ <br /> Disposal Field (Specify Requirements) - <br /> -------------------------------------------------------- <br /> ------------------------------------------ <br /> ----------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 San 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 to becothat in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as become. subject to Workman's Compensotl6n laws of California." <br /> Signed ......--------------- ---------------------------------------------------------------__ Owner <br /> Title ---------- ------- ----- ----------------------------------------------- <br /> --- --------------------------------------------------- <br /> By ------ <br /> t <br /> .4�p if of owner} <br /> ATMENT USE 9NLY <br /> FOR DEPA <br /> ------------------ DATE ------------- <br /> .,.APPLICATIC)t4 ACCEPTED BY ----------------------------------------- --------- --------------- <br /> ? .........DATE ----------------------------�­­-------- <br /> ------------------------- <br /> 4. UILDING PERMIT ISSUED --------------------- --------------------------------- <br /> -COMMENTS ........ --------------- <br /> ADDITIONAL ....................... ................... ----------------- ------------------ ----------------------------------------------------- <br /> -------------------------------------------------------------------- ---- <br /> ------------------- ---- ------ ---------------------------------------------- ----------------------------------------- <br /> 'I' ------------------------------------------------------------- ----- <br /> • <br /> ----------------------I--------------------- -------------:--------- <br /> ------------------------------------------------------------------- -----------------------------:-------------- ------------- <br /> 16 -------/ _,_�_/k_------2_1 <br /> inal Inspection by; -------------- -------------------------------------------------------------- <br /> -- --------Date --- ------- <br /> SAN JOAQUIN LOCAL F(EA_LTH-dTRI�W, <br /> Ef. 9 J-'68 Rev. 5M <br />