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r USE: <br /> �_- . <br /> .. - ___. _ ........ .i <br /> .... ..---- '--....... .. ..-j Tin€sFerrnitEa:gtir�h 'iearFromDc [s_E:a� c.a._ .:s�... . ..:........ <br /> ... _ <br /> �+ Application is hereby rnode Fo the Sar, Joaquin Loca'i Health Dls`rict for a permyt to construct onc,' instal the work herein <br /> des�ribeIl, This opplicaticn is ,✓node in compliance witli County Ordinance Nc -v onc' exisiin.c Rules ar� Reguiat?ons- <br /> JCB ADDRFSS/LCCA I�N t7 Cl CENSUS TRACT ................. <br /> ..... ' <br /> Owners Nome ............ o a e. ...... ............. <br /> Address .!-. 7�.-... _ C' .... 7 �. j _City ---..._................. <br /> Contra_tcir s Name-.-------- -4'l<< f :. ��t:c' i'L11.. .. _ License <br /> Phone ----... <br /> Installation will serve: Residence[Apartment House❑ Commercial❑Troller Court 1❑ <br /> FMotel <br /> ❑Other---------------"--' -- <br /> Number of living units:.---�-_-- Number of bedrooms 3-__--_Garboge Grinder .........-. Lot Size :.. f-_4..:- ------ <br /> Water Supply: Public System and Carne ----' -------------------------------------------p'' - ----------------------..._..- Private <br /> Character of soil to a depth of 3 feel': Sand❑ Silt C: Clay E:) ,eat© Sandy Loam Clay ,Loam ❑ <br /> FHardpan❑ Adobe❑ Fill Material---- If yes,type............................ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.j <br /> f} NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 24U feei,l <br /> ! <br /> SiLiquid Depth <br /> PACKAGE TREATMENT (] SEPTIC TANK[� - ze_ J J <br /> ._ -1..-� '-- - .d}"-------- <br /> Capacity_� .0.0(71'4Type _.. ... Materia!_---_-s'U .:.:... No. CompaRments _- ,--.-_-------- <br /> Distance to nearest: Well _...__... Q.`---.......-----_Foundation...-��'_.r___.._____Prop.Line <br /> ;I LEACHING LINE (� No. of Lines ._3---------------- Length of each [ine___[f 4._-............._-- Total Length -..�2-. .......... <br /> " 'D' Box .-.....-..._ Type Filter Material ... ?.. 7_-__-Depth Filter Material ......L!i..,..... <br /> -_---------------- <br /> Distance tt� nearest: Well -------- ....... Foundation ..._-/S?-�....... Property Line __--_ -,.-...__ <br /> SEEPAGE PIT [ ) Depth .................... Diameter ..._-...-...... Number .._---.---------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth ----------------------------- ----"---Rock Size '....----'---"----- - <br /> Distance to nearest:Well ..................._-----------------.-Foundation ............ Prop. Line ....... -_-.-- <br /> t REPAIR/ADDITION(Prey.Sanitation Permit# ..................-.... Date ___-------------------------I <br /> Septic Tank (Specify Requirements) ......._................................................ .......- ------- -- -.....----------------------------- <br /> Disposal ,Field (Specify Requirements) -..._-_-------------------_ ...-..--....-. ------- -- --- ------ ...--"---.... ---------------- <br /> ------------ ................-------------------------------.. .... <br /> ..--"'-'--- -- --- ---....._...--"---"---............. .-....-...---"--' <br /> F ...........................................................' - ' .-- - - - - '--.. _...-a-'--"----------- --- --------------------....'-'-' ' <br /> r_ <br /> (Draw existing and required addition on reverse s'sde( <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sato Joaquin <br /> County Ordinances, State Laws, and Ruies and Regulations of the San Joaquin Local Health District.Home owner or licen- <br /> sed agents signature certifies the following: <br /> f! "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 W rl�mnn's Compensation laws of California." <br /> Signed............... 7...... ---------------- <br /> By <br /> - Owner <br /> By..........................- - itN: ...- :._-.. .. � - Jifile.......-<T !... -... <br /> Ilf other than owned <br /> FOR DEPARTMENT U5E ONLY <br /> APPLICATION ACCEPTED BY .. - ..........................-.....--" ----...- " " DATE_V:.--- Q-'.70 ------ <br /> BUILDING PERMIT ISSUED_..._..- ......................................................,....---'-------...--..:-...--..--..-DATE............................ <br /> ' ' <br /> ADDITIONAL COMMENTS......................-'--'- ------------'--'----.--.-.--.--.--.--.--.--.- <br /> _..-... -....-_........-------------.----.--.--.--.--.--.--.--.--.--.--.-- <br /> ---..--...-...--...--'--...--'-- --- <br /> -- <br /> -- <br /> -I <br /> -- <br /> --- <br /> -- .....................------------ ---- -'------.._-.......--..--...-....---...-..._..---------------------'------------ ---------"---'---'-7`r - -- <br /> Final Inspection by:.- i€.L ...--.. -r ..... ' <br /> - - '-----'-'-------'--'............. ...-- -- --------.Date ---. .. <br /> ! I SAN JOAGUIN LOCAL HEALTH DISTRICT <br /> E.H.9 1-'68 Rev.SM <br /> 0 <br /> i <br /> r <br /> i <br /> v <br /> i <br />