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3FOR OFFICE USE: APPLICATION FOR SFOR OFFICE USE: <br /> h ,. IITATIOPERMIT <br /> ---- ------------ -it-------- --------------------- 7 - J--- <br /> (Comd& in Triplicate) Permit Na__.-_�_____________ <br /> Date Issued..,._.-... . <br /> This Permit Expires `I Year From Date Issued <br /> Application is hereby made to the San Joaquinoca! Health District for a permit to construct and install the work herein described. <br /> This application is made in comp!' ce with CourityOrcinaficeXf�o. 549 and existing Rules and Regulations: , <br /> JOB ADDRESS/LOCATION________ _______"".., _--_ <br /> --- ---------------t---.CENSUS TRACT------ ---------- <br /> ---- ----------- <br /> Owner's Name ----------M ---------- = - =--------- --- Phone.- <br /> . . ..... .. ... <br /> AddressT�;} �7� *. ` .._ CifiY --- ZiP <br /> -- ---._ _ -. - 4 _ <br /> . .r. - • . . <br /> Contractor's Name-__ r'2 _L. �T�l_t47 1'__ d� ,f�±r _ _€A<, __._.License #57_.3"—"A --------_t_Phane <br /> - <br /> Installationlwill' serve: Residence Apartment Hous ; Commercial ❑ .Trailer Court El <br /> Motel ❑ ; Other--,'---"---=---=----- ----------- <br /> N <br /> ----- <br /> Number of Living units:_.:: ._. --.-.Number of bedrooms:-.__ Garbage Grinder------------Lot Size----------- of c _._ :._> _.:____ ".. <br /> Water Supply: Public System and name__.____.___ <br /> r -------'--=---- - <br /> ----- -------------`--.-------- --------------------------- - W. _ -- .--------- <br /> Private <br /> e <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[] 'Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam j <br /> Hardpan ❑ ' Adobe Fill Material__..."__._lf yes, type__________________ <br /> (Plot plan, showing size of loft, location of system in relation to wells, bbildings,.etc. must be placed on reverse side.) <br /> NEW 'INSTALLATION-�(No septic tank or seepage pit permitted if pudic sewer is available within 200 feet,) <br /> - - I <br /> uid <br /> t : [ ] SEPTIC TANK ))(J Size - ¢I-- ---- �9G---.....No. Com artmentDepth- ~ f i q <br /> PAS KALE TREATMENT Capacity_.] G.r. .._,Type.--.---_______________Materia p <br /> Ice to nearest: Well. r <br /> it a ---- - --------------------------_Foundation— Prop. Line-- ------------ <br /> Dist ---. <br /> LEACHING LINE [ I No. of Lines-----------------------------:Length of each line------------- - ------Total Length..--------- --�6 _______-___-_.-_- -- n' <br /> cl <br /> D ,Box__'_____.__.Type Filter Material'. ----Depth Filter Material_____________________________________ Ok <br /> ii <br /> . <br /> ( Di ta�ncato nearest: Well ._ f-�.--- Foundation. --------------------------ProperfiRoin Fill ��(Ye <br /> i k � <br /> SEEPAGE PIT (� Depth_ _ -_.-.-____Diameter, _,; ".____Number__._ ___- ed ,K No ❑ <br /> Water Table Depth - -----------------------: --- --- Rock Size- 7`v_ -------------------- <br /> . <br /> Distance to nearest:,Well..__ .Q. -----------------------Foundation-------2,9-----_.___._`_.Prop.'Line.-- <br /> REPAIR/ADDITION (Preva Sanitation Permit#_____YR- ------------------ ="___.__._ Date---------------------------------------- <br /> 1 ; <br /> SepticTank,(Specify Requirements( 2 e7 _•.__ ----=----= =-==----==-•-----=:_.:---=----------------------------------------------------------------------- - <br /> Disposal Field(Specify Requirements)_.IG . �" ':. = =----------------------------------------- ----------------------- <br /> j (r ., <br /> ------------------------------- ----------- _J <br /> ----k---------------- <br /> ': - ----------------------------- I <br />- t .' (Draw existing and required addition on reverse side} { <br /> I hereby certify that,] have prepared this application.'and that the work will be done in accordance with San Joaquin•County <br /> Ordinances,' State'La'ws,and Rules and Regula:tions\.of the San Joaquin Local Health District, Home owner or licensed agents <br /> signatur certifies the following:` �; I <br /> "I certify that in the performance of the work for which this permitris issued, l shall, employ anyperson in-such manner as �. <br /> to b900ject to WorkmanC' as,-oCalifornia."wS.gn - - <br /> = - Title <br /> e.r <br /> ------- ------- ' fit <br /> -- ---•-------------------- ------ <br /> �(lf other than ow6er( <br /> FORD RTMENT US ONLY »+ <br /> APPLICATION ACCEPTED:-BY' ------ <br /> DIVISION OF LAND NUMBER. -------------- ------:.. --- -- DATE <br /> ------------ <br /> iADDITIONAL COMMENTS"---------------"-___.____._ - <br /> y -----` , <br /> .. - �S --- ' -------------__.___.__-------- ._..__-----/-/- <br /> - <br /> -' <br /> � <br /> ./{------ <br /> --------------------------- --------- _ ------..-..------------.`-.---------------------_-----_---------. ----------------.--.-------------------------------------=----- _------ --------- -- ------------------------------ ----------------------Date--- <br /> 'I Inspection by;Fina------------------------------ -- ---------- ------------------ ----------- ------------ -------------------------0*4- <br /> EH <br /> 13 241, -. <br /> t . . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTF&5 21677 <br />