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FOR OFFICE USE: <br /> apPucaTicN FOR saNrraTIoN PERMIT <br /> Xomol•te in Triplicate! <br /> Permit No. ..� +......... <br /> This Permit Expires 1 Year From Dote 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 appl�alio� is made 'n compl'anc9 it <br /> County Ordinance No. 549 and existing Rules and Regulations: <br /> �� �G �� �� S.�c r� �NStSt <br /> JOB ADDRfSS/LOCATION ..- _� . --. .....�`�. .i....... ... .... . . ........ S TRACT ......... ................ <br /> Owner's Name <br /> Address ..... ... .................. . <br /> Contractor's Name ......... Ciry 7 <br /> ..................License # . ;, Y ,1 Phone <br /> Installation will serve: Residence❑Apartment House 0 Commercial ller Court ❑ <br /> Motel❑Other........................... ............... _ yy �.,( <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder ............ Lot Size . .14..:.L.�t//7 . <br /> Water Supply: Public System and name ..............................................................................................................Private <br /> Choracter of soil to a depth of 3 foot: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam 0---- <br /> Hardpan 0 Adobe 0 Fill Materlat............ If yes,type............... ......:..... <br /> (Piot 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......LR C P...................... Liquid Depth ....1f.................. <br /> Capacity .LAVA.... Type ... ...... Material...................... No. Compartments . ............ <br /> W <br /> .. .... <br /> Distance to nearest: We N _. P......................Foundation ../-/P............ Prop. Line . ��............. <br /> LEACHING LiNE [ j No. of Lines -------J.............. Length of each line.....y0................ Total length ............................W <br /> 'D' Box ...1...__.. Type Filter Material .../.1jr.....Depth fitter Material f..r................................... <br /> Distance to nearest; Well Foundation ........................ Property Line ........................ <br /> e SEEPAGE PIT [ j Depth -------------------- Diameter ................ Number ............................ Rock Filled Yes ❑ No (3 <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation ----....._.. ....... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> SepticTank (Specify Requirements) ............................................................................................................................................. <br /> Disposal Field (Specify Requirements( --------------------------------------------- ----------------------------------------------------•-----------.................----.. <br /> ......................................................--................................................................ ...... .................................................................... <br /> ------------------------------ ............-............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son 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: <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 becomes b to Workman'�°mpensatioo�t la of California." <br /> Signed ..... ] _. � !L�- �,�1t1/��. .................. Owner <br /> By ---- ............. ....... .................. ............................... Title ...------ -- - <br /> (If other than owner) <br /> _ R DEPAR ENT USE ONLY <br /> APPLICATION ACCEPTED BY _�. .. ..... . ..... -- --- -------------- ------- DATE 7---..--... <br /> BUILDINGPERMIT ISSUED .................. ...... ...... .... ........... ................ ..... .... .:..._ ...............DATE . _ ................................. <br /> ADDITIONAL COMMENTS ..._.-.- -- ... .... . <br /> .....- _... .-._..- _--.� <br /> Final Inspection by: ... .. ... _ .. . . .............Date .._.. .- "� :�';- <br /> ........ ..... ...... <br /> Edi 13 24 1-68 iILv• 5M SAN JOAQUIN L, x HEALTH DISTRICT 8/7jt 3M <br />