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FOR OFFICE USE: APPLICATION FOR 5 1TATION PERMIT <br /> ............. • --- Permit No. . r-q3 S <br /> (Complete iTriplicate) <br /> Date lssuedlZ.4` 7=5 <br /> . . <br /> ................ ............. This Permit Expires/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 here4n <br /> described, This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....-. CENSUS TRACT .....................::... <br /> Owner's Name ........ .I b�e 2-: --._... •i f° 5.................. Phone --- .......2....... <br /> Address .-._ �. .cO_�Ga.... ...... / ------{0-�—-----� ..__._.. City ���- ----- -•.......... ...... <br /> License # ... <br /> Contractor's Name ..�i - �. �r C Phone . .._. . <br /> Installation will serve: Residence�(Aportment House-E] Commercial ❑Trailer Court 0 <br /> Motel ❑Other ........... ------ - -----------------_... <br /> Number of living units:............ Number of bedrooms .........---Garbage Grinder .- Lot Size .......... <br /> Water Supply: Public System and name ---•----- --------------------------- ------------- -------------------- .................................Private <br /> •FC3iaracter of soil f a depth of-3-feet; Sand❑`Silt❑ ­Clay ❑ Peat❑ Sandy Loam Clay.foam❑"� ' " <br /> Hardpan ❑ Adobe ❑ Fill Material If yes,type ............................ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must Vbe 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 TANK'[ ] Size.-----------------------......-----..._.-..:.._ Liquid Depth .................... <br /> .._...� <br /> Capacity . - Type .................... Material........ --.-... No. Compartments ............--......... <br /> Distance to nearest: Well ... ......................... .Foundation Prop. Line ..._.•--....._._...... <br /> LEACHING LINE C ] No. of Lines ... Length of each line ........ ................. Total Length ............ <br /> 'D' Box ._... ... . Type Filter Material -------------------- Filter Material ....... .....................-.-..-..--. -..- <br /> Distance to nearest: Well ...........----------.__ Foundation . ::.................... Property Line ...-___......--. ....... <br /> SEEPAGE PIT [ I Depth . .. Diameter ..--------- Number ............................ Rock Filled Yes ❑ No ❑ <br /> Water .Table Depth ........ ..............................,--Rock Size _...._._. ...................... <br /> Distance to nearest: Well .-------------------------------- ..... Foundation .._.... ....... Prop. line --------- ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _...... ----- ...................... Date ----------------------------•-----) <br /> Septic Tank (Specify Requirements[ .... .......,-.�-.._ ...�.. ®..�..._. :..r._.. _-. <br /> Disposal F' Id (Specify Re uirements _ . _-_. ...............- .......................n. L. ....,. 1-.e- . -.­----­-­ ---------­-------­....-.-_...._....--._.... .... <br /> ." ............. <br /> ........... <br /> —may �•., � _: - -- . . .�•;, ..- -� � �;-- <br /> ......................... ..-...- -:--- ................--.. ....----.... ................._... ..... --..._..............._......----- <br /> (Drdw 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 bec IL s ) ct t ork 's Compen tion,46v3�s pf Carnia." <br /> Signed .. _........_.. _._. -... - r_.---- --�..---- . Owner <br /> By . .: Title " <br /> er than owner) <br /> Alp- <br /> _ FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY �,. - .._.. ................ DATE .-.,. . ........ , <br /> BUILDING PERMIT ISSUED -- - --------•---�-f- DATE . ....-- ................... <br /> ADDITIONAL COMMENTS ..._.._............... --. <br /> ............................................... .................... - ...........-........................ <br /> ................................ ............... --- ..........................:..................-------------- • ... ..-----...,----------._..._. <br /> Final Inspection by- ----------------- `' .. •---•------"-- --------..-..----•- ------------.....Date _.-....... <br /> 1 <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> i <br /> 13 24 , 7/723 M ___ <br />