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ys <br /> FOR OFFICE L1SE:r b. <br /> APPLICATION FCX SAIAITATION PERMiT <br /> " <br /> Perrin it No. .� <br /> (Complete in Triplicate) <br /> .._.. ..._.. This Permit Expires I Year From Date Issued Date Issued ....... -7� <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION g3. -- .. .U._ 'G2�/.i .- .-A(/ .....CENSUS TRACT ...�:. �.._ <br /> Owner's Name .._... �/ _.-..:SG_Q77—�••-----------------, -----------------......Phone .................................... <br /> Address •-_...-- ••-•....................•----••----..._•--•-----•. City •--•-----•------... --- --------- ......................................... <br /> Contractor's Name ..../4.c. ,...,l t'1.4�_4..?el----------------------------------------------License # ... Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other .:............................._...__..... <br /> Number of living units:..... ..... Number of bedrooms ...Q......Gorbage Grinder ............ Lot Size .-...-- <br /> Water Supply: Public System and name ........................................................--------------------------------------......... Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loam ® Cloy Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material --------- __ 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.) Q <br /> NEW INSTALLATION: (No septic tank or seeps it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { } SEPTIC TANK Size.-6_2 .S._X..94i ------ -------- Liquid Depth ...6�v..-....._...... [V <br /> Capacity ./.-........-... Type`RR4 GX6?a Material---------------------- No. Compartments --- ----_-_--- <br /> stonce to nearest: Well .._..S®................ .....Foundation :.C_............. <br /> . Prop. line . 1 ......... <br /> LEACHING LINE [ke No. of Lines ...... . ... Length of each line-----2d................ Total length ... .. P.._............. <br /> 'D' Box -----I..... Type Filter Matti erial ..&�Y441Depth Filter Material ------ ......... <br /> Distance to nearest: Will ...Is0'I.......... Foundation .VL?--------------= Property Line ................--_-__ <br /> SEEPAGE PIT [ ] Depth .................... Diameter ................ Number ........................... stock Filled Yes ❑ No ❑ <br /> ' RockWater Table Depth •••...--._ •-•--•-- ................ <br /> Size -------------------------•••---• <br /> Distance to nearest: Well ....7....................:.......�:'--:.Foundation ...__.......-... --- Prop. Line ...................... <br /> Date ....................••-----•-•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ... Date -) <br /> SepticTank {Specify Requirements) -------------------------------------------------- -----•-••----------------•------------•---.--._.-----....._------------------------•----. <br /> Disposal Field (Specify Requirements) - L - <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 San Joaquin Local Health District. name owner or licen- <br /> sed agents signature certifies the fallowing: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ... .. i. . _ .....I................ = ------- Owner. <br /> By . . .. . .......................... •-------......----- ........................................ xitle .................................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE xONLY <br /> APPLICATION �. - <br /> -. <br /> ACCEPTED 8Y ...: �.F - .._... ................ DATE ..... ...... <br /> BUILDING PERMIT ISSUED ............... ___..--._-_----_-.--_ -_--.-----__-__------DATE ....................... <br /> ADDITIONAL COMMENTS .. - - ------------------------------------.............• •--°--------••--..._.........._......:.............. <br /> ...-- .....__... .... - ------------------­---------------- ------- - --- .....: ..._...... <br /> ........ .... .. -----.---....----- ---- --A <br /> •--••-. ----- ------ ti <br /> Final Inspection ��1� •. 4_ _ •................._.. :......:__Date . , � ---- <br /> l .., <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />