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FOR OFFICE LISt - <br /> APPLICATION FOR tki4lTATION PERMIT <br /> {---------=--------------------------------=--- ;Complete in Triplicate) 7 3w3 <br /> Permit No_ __ _________________. <br /> ---------------------------- <br /> Date Issued <br /> -------------------_-- <br /> This Permit Expires 1 Year Fram.Date Issued <br /> %111 V 1 <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 compliance with County Ordinance No. 549 and existing Rules and Reguldtions: <br /> - � <br /> JOB ADDRESS/LOCATI.ON ._2.006 ------E------R)-V-� --------RV -----------------------CENSUS TRACT _ ------ <br /> Owner's Name _. t_��-It ___FAR S-----------9------REARU._Ey------------ ----•-•-•---- <br /> Phone -----_---- <br /> ----- z <br /> Address ---------,� -��-f��---�------�L�-�-------�,�------ ------------ CitYL---- --- .���r ----•----------------- -- ----------- <br /> it <br /> Contractor's Name __ 1!' ------------------------------- License # --------------- --------- Phon <br /> Installation will serve:fr Residence ❑ Apartment House Com <br /> mercid ❑TrailesrQevr-t <br /> Other <br /> 37 <br /> Motel LotS <br /> ize _ _ellNumier of living units_____ Numberof �droom __Garbo a Grinders ___ <br /> Watername, <br /> . i <br /> L <br /> Supply: Public System and name:---------------------------------•---------------------------------•°-----------------------------------------Private' <br /> Character of soil to a depth of 3 feet Sand H]--Silt:] Clay ❑ Peat❑ Sandy Loam �lay Loam ❑ <br /> Hardpan E] Adobe E] Fill Material _&�_ If yes, type ---------------------------- <br /> (Plot <br /> ________________________ __[Plot plan, showing size of lot, locationof system i relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank r. seepage pit perm`tted.if publli� sewe s is av ilabl within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAf WKi :[ ] Srze__________________________________.-_--.______ Liquid Depth -------------------------- <br /> Capacity <br /> _____ -__!---__________Capacity ------ ------ Type --- --------!------- Material---------------- --- No Compartments ---[_[. ------=•--- <br /> f Distance to nearest: Well ---- ------- ----------------------Foundation ---------- ----------- Prop. Line ....1--1) . <br /> LEACHING LINE [ ] No, of Lines _._ "- L_ _� eng—h of each line___________________________ Total Length _________#,_��_r.._....____ <br /> ,��------_. <br /> D' Sox ------_-'---fType Filter M terial ----------------- --Depth Filter Mat r.ial -----------_--- ----..---!---- ----•-.---- <br /> Distance to nearest: Well ______ ____________r Foundation ________________ ____ _ Prbportr line ---------:.............. <br /> SEEPAGE PIT [ ] Depth ----------�'_ ____ Diameter _________ ______ Num er -------------------------- Rock Filled 'Yes E] C No <br /> Water Table Depth --T---------�------------ ----:Rock-Size ------------ '---------- -----Distance to neares#: Well ._____ <br /> Foundation Prop. Line T-----•---- <br /> t <br /> iu <br /> REPAIR/ADDITION{(Nev. Sanitation Permit# ------------------------------- _.__ " Date ---------------___________________) <br /> t <br /> Septic Tank (Specify Requirements) ---- - -----f__ R'C--�---- -3 �r <br /> N�---- `J-{-C_: .�-----__�------------- <br /> Disposal Field (Specify Requirements) �__ ________4vgI_P_W-____—V._T�S)____ t174___.____�---------- ©1 -- --- f <br /> j1 - <br /> [Drp` existin and-requirecL dditior) on revbrse side) <br /> I hereby certify that I have prepared ;this application and'. hat the work will be done in accordance with Sanl :i— <br /> oaquin <br /> f County Ordinances, State Laws, and Rules and Regulations�of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signatu certifies thefo lowin) '• <br /> ' "I certify a int performance t e ork for v#ih thispermit is issued, 1 shall not employ any person in su ch manner <br /> as to bec sub ct to W kman' om ensati n aws_of_California: <br /> Signed -- -- ------ ---------------- --------- --- ------------ Owner <br /> k BY --------------------------------------------- o- ) Title ' <br /> ----------------------I---------- --------------------- <br /> (if other than owner) t j <br /> I FOR DEPARTMENT USE ONLY #6 <br /> BUILDING PERMI.TwISSUED:=.---------— -----�'----------- ---------- -- ------ ---------------------------------- DATE -- ---------�®--- -------- <br /> APPLICATION `ACCEPTED BY __________ __4___�`_________ <br /> ,.�._ ,�.-a __DATE ._ - - - - -------- --1--- ---------- <br /> ADDITIONAL COMMENTS' -- ------ --- ------------- - ------ - ----- <br /> ------ -------- --= - - --------- - --- - - ---------- <br /> ----------------------------------- --- ----- - -------------- ' <br /> ----- --N-------------------- - -- - =f# -- <br /> P'- ' f { i !'S _ <br /> Final Inspe -, Y Ddte_ l�:J.:. <br /> F -- <br /> SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />