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FOR OFFICE USE- <br /> XC) <br /> . 0- //, FOR............... Permit No. <br /> [Complete in Triplicataf t <br /> .............. ............ .........I........ . _ H ' -Date Issued <br /> '"" Thls Peneilt Expires 3 Year From.Date issued <br /> Application is hereby made`to th SanlJoaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application:is.mode in compliance with County Ordinance No. 549 and. existing Rules and Regulations: <br /> r , <br /> JOB ADDRESS/LOCATION .:.................1.:..CENSUS TRACT .:........................ <br /> i <br /> Owner's Name .. 5//h ' ......c��ilft �ll .d' ...:.}. ... }. <br /> a ' .Ph"one I <br /> Address ._;;Z��f 1_. f 1 w .l l ........... ...:. Y .'C€ty ' 4ir .;...._._. .'. ..... ........_.._,_ Y <br /> I , <br /> fry �� W ...Lire , <br /> Coniractar's Nacre _ l�'1 -- �t'C.t� �... 'i-----=------- <br /> � nse # �,S:�a�L./.�.�. Phone�,�.�.D.aS I <br /> Installation will serve: Residence Apartment House 1 Commercial .� i <br /> Q P f� �'Traper Court 0 <br /> - -- <br /> Motel ❑Other..D4i�.S--------------- - <br /> Number of living.units:_.. .... Number of bedrooms __Z....Garbage Grinder ..... `-., ............. _ ....................... <br /> i `! <br /> Water Supply.-Public3Syste`m and name . •4 � �..........._... .........r ..............:'.......:.......Privote © �l E <br /> Character of s.oWto a depth of 3 feet: Sand[] Silt Q Clay 0 Peat 0 Sandy Loam'O Clay Loam 0 <br /> = <br /> Hardpan[-) AclobeX Fill Material ............If yes,.type.............:.. ....:. .. <br /> (Plot Won, showing size'of, lot, location of system in relation to wells, buildings,}ete.-Must"be placed on' reverse slcleJ?� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,I ti <br /> PACKAGE TREATMENT [ 3 SEPTIC TANK I ] size..............................:........... <br /> Liquid. Depth 3, <br /> �(ts �� <br /> capacity -•-•---- Tyle ------------ . Material............... No. .Cgmpartmen sj ..................... �. <br /> #P. Distance.to nearest: Well Foundation ...................... Prop. Line . . <br /> IF <br /> LEACHINGiINE ]' !.No. of Lines ..__-_1............... Length of each line...._7.. . • Total length .. .,7 ............ <br /> 1[t5 �1G 4� V Box _.. Type filter Material Y�X- -_.Depth filter Material 1 ��............................... <br /> f <br /> t Distance to nearest; WeFoundation ../49.............. Property Line `....+ice4!�............... <br /> SEEPAGE PIT ['a�....,._� l # .. ...... Diameter � .:..._. Number ....---- ,.... """'Rock Filled Yes No �] <br /> Water Table Depth .. .....Rock Size . . <br /> Y <br /> Distance to nearest: Well ...................Foundation Prop. tine .:J............... <br /> REPAIR/ADDITION.IPrev...Sanitation Permit+# ........... ..........................:.... Daae --...:.......:..:.:....::__...__.} <br /> Septic Tankx(Speci.fy Requirementsl.................... .................... <br /> Disposal Field (Specify lRequirements) ____a.0- Z6.--.._..X.?"�_.- ,. 1_._.!.............. <br /> .f l , <br /> , . <br /> ._._ d�..`._,, ? .` c., .G ......... .................. <br /> Draw existing d required addition on reverse sidel ..."'- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance w1th.San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or ilcen- <br /> sed agents sigi5ature certifies the following: <br /> "I certify that In the perfcrmanc" f the work for_whkr ,thli permit ii Issued; I1hall not employ any person in such manner <br /> as to becomeApblect to (Workman's Compensation laws of California." <br /> Signed ,(- `----------------- Owner <br /> By ------7-owner).. <br /> = _ . ............. Title .... _ ................. <br /> (If other tha � <br /> T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ 1^---� <br /> DATA f : <br /> - ------------ <br /> BUILDING PERMIT ISSUED __-------_-.:'`.---_-_-_ -_- _ DATE ........... ..................... <br /> ---------------------• <br /> ADDITIONAL COMMENTS -•-• .......... <br /> - tom..... ....------ <br /> j------- 1 <br /> ------------------------------- ------- <br /> -------------- --------•- ----- - _ - <br /> ------ - - --- ----.....--------------------- .... ....----------- ......-- • •-- -- .. <br /> Final Inspection by: ----- --- --._ -�_ = -----------------_-..._....-._...:Date _. . =I/=T�...-•-.---- <br /> 4 13 21a 1-6 i AN AQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />