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FOR OFFICE USE: APPLICATION FOR $A*, TATtbN PERM <br /> 6. <br /> Permit No. . .. <br /> i .......... . ...... IComplate In Triplicate).... 7 <br /> I D to Issued Date Issued :..�..... <br /> This Permit Expires 1 Year from <br /> ........................................................ <br /> . a <br /> Application is hereby eriade to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application !9 made In compliance with County-Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA tT ON .1. � ... ..��...... .................................CEN5US TRACT Q . ............. <br /> Owner's Name . . ..: .......... 4'...-..lr •••.... ............. Phone -T ...f l�� ....... .. <br /> Address ............. ._..1.`f ... ..._... 5,J�7._.. --.........City ... .................. ---.... <br /> se <br /> Contractor's Name ... ...5 :...:::::.... Licen # ..� .._ Phone . 1..0 ..... <br /> ------------- <br /> Installation will serve=-_ } Residence Apartment=HouseIO-Commercial❑Trailer Court ❑ <br /> Motel❑Other <br /> Number of living units:.......4 Number of bedrooms ....Garbage Grinder ��t SSize ... �. .. ' ...... ...........� <br /> Water supply, Public System and name ...................._: .. --.....-..-••-••--•--g.......—.......-----�t =Y•_'�:= ..................Private [� <br /> Character of soil too depth of 3 feet: Sandl Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam❑ <br /> Hardpan p, Adobe 4 Fill Material ............If yes,type............... ......•..... <br /> !Plot pian,;showing size of lot, location"'c£ system Inrrefation to wells, buildings, etc. must be placed on reverse slde-) <br /> NEW INSTALLATIONS. (No septic tank or,seepage pitr permitted if.public sewer is available within 2134 feet,! <br /> PACKAGE TREATMEN -1SEPTIC TANK{-)- -= <br /> T�[.� Size................................................ Liquid Dept _..........., ............ <br /> ` _" ... `-Materlol...................... No. Compartments <br /> Capacity ._.. . Type ... ._.. ................. <br /> • �` Dlstance. to:-nearest: Weil - ................Foundation ____.................. Prep. line .._,................ <br /> ..... (11, <br /> ' <br /> LEACHING LINE No. of Linea _ '� Eength of each fine....:...---•-..:............ Total Lengthth <br /> .......................... <br /> r --- <br /> '0' Box <br /> ------------ Type Filter Material .....Depth Filter Material ....s.._................................. <br /> b Distance to nearest Well ........................ Foundation ...............•.•. Property Line ........................ <br /> `— Number Rock Filled Yes ❑ No <br /> SEEPAGE PIT [ l pth Diameter <br /> WaterTable-Depth ................................................Rock_Size...._........,. ...........:.....- <br /> Distance to nearest: will ..............•_.__.....................Foundation .................... Prop. line ................. <br /> -•--•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit P .. Date Q -----•-••1 <br /> Septic Tank (Specify Requirements) --- ......... .. ... ._!,�' .. .='�`- '�`-�• .��°U ;� <br /> Disposal Field (Specify Requirements) ....... �- ! >. .� '_`` �3` 2............................... <br /> •------••-- •...............................................................••----...----...........--••--••---....:__.................-•----.....................----.................................. <br /> (Draw existing and required addition an reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Sam Joaquits <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home Owner or licca• <br /> sed agents signature certifies the following: ' <br /> "I-tertify that in the performance of the work for which.this permit is issued, 1 shall not employ any Porsan In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> 4 <br /> Signed Owner <br /> . <br /> sy ..................... . xltle ._...................................................................... <br /> (if other owner) <br /> :FOR DEPARTMENT USE ONLY <br /> . S <br /> 'APPLICATION..ACCEPTED BY ..... .. DATE ..... Z. -: <br /> ..... ................._............ <br /> BUILDING PERMIT ISSUED .........................................•...........:............ _.:........ DATE ...................................,....... <br /> ADDITIONALCOMMENTS .............. .........................................._.. ............................................................................................... <br /> ................................................................ ............................................. <br /> ........ <br /> ...................................................................... ...--.----..... ................. - ... .......... <br /> Final Inspection by: .... .. ........... .4"1 <br /> - Q.�.�'�,e... . .... ............ tg,......... . ... . .. �_............ <br /> ............... -- _ <br /> EH 13 2!t 1-68 &v• 5K SAN ,JOA UIN LOCAL HEALTH STRICT <br />