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FOR OFFICE USE; <br /> APPLICATION p4R a,4N11TA`PI®N POM!" <br /> RillT <br /> I <br /> (Complete in Triplicate) Periitlt No. ..................... <br /> !. <br /> This Perrtilt I&zpireit 1 Year From Data isihed Date issued .................... <br /> y � <br /> Applicat€ori is hei°r�6y hiacie to the San Joaquin Local Hedlfh b1strict for a p&m1t to construct and install the work herein <br /> descrl6ed: This 6oplli dfl6h is made in compliance with County Ordinance No: 540 and ekitting Rules and Regu(tifiohil <br /> JOB AbbitE98/L6dAfl6N ..x.3.61 � .+` '.�...... ............. •......._........CENSUS TRACT ........................, <br /> Owher'b Nairn ....... IA :y <br /> . . . ..Y..y?'._........ f ..........................+ + . '....:... <br /> . . <br /> City ........ o p <br /> re§§ .............. / .l''�.e....._..........: ...............:..:..:.................. ........ . .. ....: :..:...: :. .... .. <br /> Sa.rv.............::::..:..:....Liceii§ 166�5"�� Phone �� <br /> e'# ...._.. .... <br /> Ihsiallution will &etof Residence ❑Apartment Hoose C Corn merdtil _Trailer Court _ <br /> Mintel 0 Other <br /> Number of liviiig i tiit§i..... ...... Nurnlaee'iof bedrooms, .:J_.;:,_.Garbag e.Gel nder ............ Lot Size :...-'_.., .�>`: '.s............... <br /> ilVafer SU(iply► i3U61iE iystem Olid Frdii,e 'L................................................ rivdte <br /> P <br /> CFiui•dcter of 011116 d depi'h of 3 feert Sand;R Silt❑ Clay ❑T Peat Saridy Lodrri Clay loam <br /> Hardpan {] Adobe ( Fill Material .:°.......... if ybi;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 INSTALLATIONt (No septic tank or seepage pit.permitted If public sewer is available within 200 feet,( {, <br /> PACKAGE TREATMENT SEPTIC TANK( Size.....Y...'A... .Z.................. Liquid Depth ...y.................... , 4 <br /> XS X <br /> Capacity <br /> .1. <br /> Type 8tf-..e1Ji . Material..C p.^'..�:.... No. Compartments A................6 <br /> �l , :..............Foundad • /061 <br /> Distance to nearest. Well ........ a . p• lime . .... <br /> ......... <br /> LEACHING LINE ( j No. of lines .. .1..:............ Length of each'line...:...�T,a. . Total length .................. <br /> 'D' Box ..../-...... Type•Fllter Material Depth Filter Material ....2p................................ <br /> Distance to nearesti Well ...J.A.R.:........ Foundation .... zo.............. Property Line J x.d........... <br /> SEEPAGE PIT ( ] Depth ..........`� ..... Diameter ............::.. Number ............................ Rock.Filled Yet ❑ No C3 <br /> Water Table Depth .............................. ..............Rock Size ......................... <br /> Distance to nearest, Well ........................................Foundation .................... Prop. Line ...................... <br /> R€PAIR/ADDITION(Prey. Sanitation Permit 0 ............................................ Date ....................... ........ .] E <br /> SepticTank (Specify Requirements) ....}.....................................................................................................•.............._...............,. f <br /> DisposalField (Specify Requirements) ......................................................................................................................I.............. <br /> .......................................................................................................................................................................................................... <br /> .... li ............' .. <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinarices, State Laws, and Rules and Regulations of the San'Joaquin Local Health District. Home owner or Ilcen• <br /> sed agents signature certifies the following:. <br /> "I certify that in the performance of the work for which this.permlt Is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California:" <br /> Signed ........F..e...AY117&VV X.. f S a ✓....................:.............. Owner, _ <br /> By .......... .rr' ....... ...................... ............. Title ......... <br /> (if other an <br /> FOR DEPARTMENT USET ONLY <br /> APPLICATION ACCEPTED BY .................. . ...................................... .............• DATE ..... ....1:71Y............ ' <br /> BUILDING PERMIT ISSUED ...C,,)...........:.................:...:..:. DATE <br /> ADDITIONALCOMMENTS ..................... ........................................_............................:........... ........ <br /> .............. <br /> .......:................ .... .. .......:....................................................................... �,r ...' ..,...... <br /> FinalInspection byt ... t .. ..........................................................,.....................Date ........... ........1...................... <br /> SAN JOAQUIN •LOCAL HEALTH DISTRICT <br /> E. H.13 241-'G8 Rev. SM f 7/72314 <br />