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FOR OFFICE USE: <br /> CAT( FOR SA . ew �rr <br /> ..................... pTriplicate) Permit No 6 f '!, <br /> .I......... .................... <br /> (Cont tette in . <br /> ......... This Permit Expires 1 Yew hem Date I"MW Date Issued /-A..- Zf- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the <br /> �work heroin <br /> described. This application is made in compliance with County Ordinance No. 549 and <br /> � exist ung Rul nd RIM St— <br /> ION <br /> JOB ADDRESS OCATION CJW!4. s.._.....?9&,b �TRACT ..."............. <br /> /L <br /> Owner's Nagme .i..l-_!-. . ..L 2- ...... <br /> Address City .................................... .._..._... <br /> Contractor's Name .....SXM......................................................................License# ........................ Phone .................--------___-. <br /> Installation will serve: Residence❑Apartment House t] Commercial❑Traitor Court 0 <br /> r <br /> Motel❑Other............................................ <br /> Number of living units------------- Number of bedrooms ............Garbt" Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ........................................................_-...................................................Private❑. <br /> Character of soil to a depth of 3 feat: Sand❑ Silt 0 Clay 0 Pea#❑ Sandy Loom 0 Clay Loam ❑ <br /> Hardpan p Adobe❑ Fill Material ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, oft. must be placed on reverse aide.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted If public sower is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK f)j� ........................................... Liquid Depth ... <br /> Capacity .................... TYPO .................... Material..._.................. No. Compartments ......................J <br /> Distance to nearest- Well .Fou tion ...................... Prop. Line .. <br /> LEACHING LINE [/j No. of Lines ...... Length of each fine........._ c_ Total Le th ... ......... <br /> 'D' Box .... ..... Type filter Mgtefla{ /... :2-0 th Filter Material .. ... ........... <br /> Sa ...... Foundation ..�1.,/� Property Line <br /> Distance to nearest; Well .............. -.-........... ............. <br /> SEEPAGE PIT ( } Depth ...-................ Diameter ................ Number <br /> ............................ Rock Filled Yes ❑ No Q <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ..Foundation .. Prop. Line <br /> REPAIR/ADDITION IPrev. Sanitation Permit# ............................................ Owe ..................................} <br /> Septic Tank (Specify Requirements) .................. ... ..............................................w......._..............._ ....... ..... .7 <br /> Disposal Field (Specify Requirements( <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 M accordance with Sat #eagtttn <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joactuln Local Noakk District. Homo owner or licew <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit Is issued, I shell not employ any person In such manner <br /> as to bacomo subject to Workman's Compensation laws of California." <br /> Sign -. Owner <br /> By ---- ----- ------ ......................... ................................................---. 7itle ..-------------.__..................................................... s <br /> (If other than owner) <br /> DEPARTME USE ONLY <br /> APPLICATION ACCEPTED BY . .- ---!........ .. ... ... ............................ .... ............. :---................. DATE <br /> BUILDINGPERMIT ISSUED ...:._.__.................................................. ...........DATE . --------- ............................... <br /> ADDITIONALCOMMENTS --------- ............:....................... ......_..._._.... - -...-........:....._..._....._.......... <br /> Y <br /> ---- ---- ---- ----••-----••. T -------------------.......-----........ <br /> - —..------. - <br /> --------------- ------- -. - :...._.. .................................._... ........-.. <br /> Final Inspection by: .. .... •-••.... ..... Oate ../ !EH ............. <br /> 13 2!t 1-6t3 Rev, 5�t SAN JOA IN LOCAL HEALTH DISTRICT 8/7h 3M <br />