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FOR OFFICE USE: <br /> APPLICATION FOR SAM PERMIT <br /> �f 1441 --------,•------ ----------- - Permit No. --------�-�-- <br /> (Complete in Triplicate) <br /> ----------•------------------------------------- <br /> 3%76 Date Issued <br /> -_-- This Permit Expires 1 Year From Date Issued <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 complionckyith. County Ordinance No. 549 and existing Rules and Regulations: <br /> Z��l <br /> Z�l <br /> O -�----------------- <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name G -------------- Phone ---------------------•---------••--- <br /> ------ ------------------ i <br /> Address - City -- <br /> Contractor's Name --------- ---- - -------- --------------.License # /''� <br /> Phone -- -- fly <br /> Installation will serve: Residence ❑ Apartment House❑-' Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other --- CL-i- e-41------------ � <br /> Number of living units:___------- Number of bedrooms ______Garbage Grinder /1'V__ Lot Size __- --_------ -- d <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ Adobe Materia__ if yes,type ---------------------------- <br /> (Plot <br /> _____________________ __(Plot 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 TAN [ ] Size----- --_-S------------ Liquid Depth � — <br /> ' . <br /> opacity _I-7� ____-- Type 04°_ _ Material �l�_(�___ No. Compartments ----_____/_._.._____. <br /> Distance to nearest: Well ________��_�______________Foundation __�_d__�____-___ Prop. Line ----------------- <br /> LEACHING LINE [ No. of Lines -----/_______________ Length ofeach I' e_- �---_-____-- Total Length ____/ 6f...__-_-__ <br /> �/ I <br /> 'D' Box f-� 0___ Type Filter Material,!/�,__,�pth Filter Material ____ _�_______________1. -------- <br /> Distance to nearest: Well ___-/--o_�_________ Foundation ---� ---- --____ Property Line _-_.J`�............... <br /> SOPAGEPi; [,L Depth l Disawfer __T_ _ Number .`_-_____ --_______ Rock Filled Yes 0 .0 <br /> X C <br /> � w Water Table Depth _______�--7/------------------------------Rock Size -•----- <br /> Distance to nearest: Well _____/-_/_0.........._-----------_Foundation __1P_1______ Prop. Line _ ----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -------------------------------------------- Date ----------------------------------) 4 <br /> Septic Tank (Specify Requirements) ---------------- --------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------=-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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. 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, i shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --- --------- Owner <br /> C - <br /> BY Q -- - -- - 1/( Jule <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- - DATE <br /> BUILDING PERMIT ISSUED TE ------------------------------------ <br /> " " ` <br /> ADDITIONAL COMMENTS � -- - '_-- <br /> -------------------------------- --------- ----------- -- <br /> - ---------- -- <br /> ----------------------------------- <br /> ------- ---- --- ------ --- <br /> Final lnsection b Date ------------ � _d <br /> ---------------------------------------------------------------------- ------------ --------- --- <br /> - ---- - ------------- <br /> p Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />