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FOR OFFICE USE: <br /> APPLICATION MRSA ITATION PERMIT . <br /> ----------- -------'--------------------------- W '^'- Permit No. -V1 <br /> F (Complete in Triplicate) <br /> Date Issued ____________ <br /> This Permit Expires l 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> �j Q <br /> ----- <br /> • <br /> L <br /> _CENSUS TRACT ------------------------ <br /> JOB ADDRESS/LOCATION � --- --�--- <br /> Owner's Name ------------ • �------------------------ ---------- -------Phone ------------------------------------ <br /> Address ---- -------------------------- <br /> ----•---------------•-- city ----------------•-----------•-----•-- <br /> --- -------------------- <br /> Contractor's Name ____________ _ _ nt House' Commercial oiler Court____ Phone ____________.._____....-____- <br /> Installation will serve: Residence ❑ Apartme ❑ ❑ <br /> Motel ❑Ot e -\:------------------------------------ <br /> Number of living units:_I______ Number of bed roams Grinder ------------ Lot Size -----Af_____------ __ <br /> Water Supply: Public System and name ------------- -------- ------ <br /> ----- - Private { � <br /> Character of soil to a depth of 3 feet: Sancl'~ Silt lay E] Peat❑ Sandy Loam {] Clay Loam 0 <br /> Hardpan ❑ Adobe F-1 Fill Material ------------ If yes,type ____________________ _ <br /> (Plot plan, showing size of lot, locat d of system in relation to wello, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic to k or seepa pit permitted if pvbINewer is available within 200 feet,) <br /> SEPTIC TANK Size-------------------- Liquid Depth <br /> PACKAGE TREATMENT { ] a [ � <br /> Capacity 2.00-- ----- Type A -_ Material�r,. -- No. Compartments ......W ---� <br /> E i <br /> ` f Foundat on " d d <br /> E 'Distance to nearest: Well v� -------------------------- - -- ----- Prop. Line <br /> o--.of Lines 1 -------- Length of each line--------- ----- Total Length ____ ------------- 0 <br /> LEACHING LINE j�' ------------- � pp <br /> Box - . Type Filter Material s-- - Depth Filter Material ____-___ --v­... .---------------- <br /> V, -•:---- <br /> istdnce to nearest:1We�iIC?_............. Foundation 10lJ�!+__ --�;�Property Line <br /> SEEPAGE PIT [ ] -Dirk th*. Diam er ______-- Number ._ _____._ --_ _ <br /> . _____---- Rock Filled Yes ❑ No .0 ' <br /> er Table Deft; - "`�= ------Rack Size ------- <br /> Distance to ne• t: Well --------- <br /> oundation "------------ - ---- Prop. Line ------=------- ------• 7 <br /> REPA�R/ADDITION Sanitdtio rmit# -------•-----. _ 4-`�� - I ate .------- --- tjx-------- <br /> - 1 � D <br /> r 3 <br /> Septic Tank'(S €eify Requir ents) --------------------------------------------------------- = t <br /> ---------- <br /> Disposal Fi�1Speclfy ��quirements} _________________________ _ } t <br /> ---------------------------------------------------- ----- --------------------------------•---------------- ------.----- <br /> ----------------------------------•---------------------- <br /> (Draw <br /> -------(Draw existing and required_addition on reverser,side) <br /> I hereby certify that I have prepared this applicationand that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations o tlj? an­Joaquin Local Health District, Home owner or licen- <br /> sed agents signature certifies the following: <br /> 'A 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 beco ect to W n's Comp ens ion laws of California." <br /> Signed A - - -------------------------- Owner <br /> --- -- - -- ---- <br /> BY ------------------ -- -------------- -------------- <br /> Title <br /> (If other- - - -thann-owner) <br /> er} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- ---__--- -------------------------------------------------.---. DATE -----��,7-2-*�---------------- <br /> BUILDINGPERMIT ISSUED ------------------.---------------- --------------- ------------- -------------- -=------ DATE <br /> ADDITIONALCOMMENTS --------------------------- ------------------------------------------------------- <br /> I ---------------------------------------------------"- <br /> --------------------------------------------------------"----------------------------------- <br /> ----------------------------------------------------------------------------------------------------. <br /> ___ __________ ____________________________________ __ _ _______ <br /> � -- <br /> Date --------- -- ----- <br /> -- " <br /> Final Inspection b Dt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> F u 0 1.'AA Riw`SM: <br />