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FOR OFFICE USE: <br /> APKICAWN FOR SAWAMN PERMIT <br /> .......................... ..................... <br /> 1C"pI*%In TriplIcatel Permit No. <br /> ..........I............... ............... <br /> Dcft lssuod ."�L-?J- 71� <br /> ..................... 2.1-J.............. This Permit Expires I Year From Dole Issued . .............. <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work hereIn <br /> described. This application is made In comp1jance, with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ..... ...........CENSUS TRACT .......................... <br /> Owner's Name .......... <br /> ......................%..... ....... .................................................... Phone ---------- <br /> ........ ......................... <br /> ...... ................'City .....2A--------------------------------- <br /> Address ..----- -.7 <br /> Contractor's Name ........................................................................................License# ........................ Phone .......................------ <br /> Installation will serve: Residence 0 Apartment House E] CornmerrJal OTrallor Court 0 <br /> Motelo Other........................................... <br /> Number of living units:............ Number of bedrooms ..Q......Garbage Grinder ............ Lot Size .....4/0-one........................ <br /> Water Supply: Public System and name ................................I .............._........_.I-I.............................................PrIvcft <br /> Character of soil to a depth of 3 foot: Sand Silt 0 Clay 0 Peat E3Sandy Loom 0 Clay Loam 0 <br /> Hardpan 0 Adobe 0 Fill M6WIaI ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in r*lctlon to wells, buildings, oft. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepaiLe pit pormifted If public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK I ] t;015,rIA141........... <br /> ....................................... Liquid Depth .......................... <br /> Capacity .................... Type .................... Mcdwicd...................... No Compartinents ............. <br /> Distance to nearest. Well ....... .................-Foundation .......... Prop. Line Zv.,......... <br /> LEACHING INE l j _No. of Lines toA.,SD......I Length of &MV11ne f I ihFilter <br /> ,6oe......... Total Length V, <br /> D' Box L...... Type filter Material ..64..........Zt, r1 rtef-mcftrlal R!..................................... <br /> Distance to nearest: Well ........ ............... Foundation ..... .................. Property Line ........................ <br /> SEEPAGE PIT E l Depth .................... Diameter ................ Number ............................ Rack Filled Yes 0 No 0 <br /> Water Table Depth ................................................Rock Size ................................ V) <br /> Distance to nearest. Well ........................................Foundation .................... Prop. Line......................... <br /> REPAIRADDITION(Prov. Sanitation Permit# ............................................ Dcft ..................................) <br /> Septic Tank (Specify Requirements) ................... ........................................................ ........................ .................. <br /> Disposal Field (Specify Requirements) ..................................................................................................................................... <br /> ................ ...............I............ ................................................................................................................... 1�........................ <br /> ................. -----------------------•---......-------•----....._----------- ........................................I.............................................................................. <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 Sm Joe"I" <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health.District. Nom owner or Neem <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 porww In such manner <br /> a to b4t!�mo stIbloct to on <br /> s rtn's Comp laws of California." <br /> Signed .. ................ <br /> ....... Owner <br /> By ........ .............. ------------------------------- -------------------- ................ title .............. ............................ .......................... <br /> (If other than owner) <br /> FOR DEPART USE ONLY <br /> APPLICATION ACCEPTED BY <br /> .......... DATE ....... <br /> ............. ........................ ..... <br /> BUILDING PERMIT ISSUED ......... ........................................I.....DATE .................... ..................... <br /> ADDITIONAL COMMENTS ................... <br /> ............. ---------------------- ........................ .........................-.................I........................ ............. .............. ............ ......... <br /> ------------------ - --- ---- -- ----- <br /> - ---- ------- ..... -------*-------- ------------------------*--------- -------------- ......*...... .............*...... <br /> ...... - --- -- ...... <br /> ----------------------------*..........­.......*...... ......*------ <br /> -I!.......... .......I............ .......Date <br /> Final Inspection by: ....... ---- .. ............... <br /> ... ........ <br /> JOA <br /> EH 13 2h 1-68 Rev. 5m SAN 4 IN LOCAL HEALTH DISTRICT 8/7h 3M <br /> r <br />