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WR OFFKX USI:: APPLICATION FOR SAMATION PERM <br /> ...................................................... <br /> (Complete In Triplicate) Permit No. .7 :.. �.G. <br /> ua <br /> ............... ........................... es <br /> This Permit Expl t i Year From Date Issued Date its <br /> 76 <br /> Application is hereby rnode to the San Joaquin Local Health District for a permit to construd and install the work herein <br /> described.This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .............................CENSUS TRACT .................. ....: <br /> Owner's Name . . . . ....... .........._.....................................................Phone g . ,.e_?. mf.... <br /> Address ..... ..................... -----.... --- ....................__..-----•--- .._...City ....------..._.. ............................... <br /> ��� �- <br /> Contractor's Name _. .�✓�".'.�..%� - •.---------------------...........................License# Phone .Y3•s.".�.l..�� <br /> Installation will serve: esidence 01partment House Commercial❑Troller Court ❑ <br /> Motel❑Other........................................ E <br /> Number of living units,............ Number of bedrooms 5.._.._Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name .............---------------------------.-.-_.•.._--_--.-_---_...----------------------------_.._:.-..:Private <br /> Character of soil to a depth of 3 feet: , Sand[] Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ day!Loam❑ <br /> F Hardpan❑ Adobe❑ Fill Material ............If yes,type............... ..... <br /> ....... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 1 NEW INSTALLATION: INo septic t k�s age pit permitted If public sewer is available within 200 feet,) <br /> r PACKAGE TREATMENT [ ] C AaNK ,- Size.. ............................................ Liquid Depth .......................... <br /> Capacity 1-2.. pe .. Material...................... No. Compartments ,2. ............. <br /> t Distance to nearest: Well ...��C`1..�... _-Foundation ...... Prop. line <br /> .............. ....... <br /> .. LEACHING LINE ( ] No. of 6nes4 Length ..- .• gt ................4y <br /> len th of sorb line.�fl.� ......... .... Tocol !en t . b�.......: <br /> 'D' Box Type Filter Material .. .. .. ........Depth Fitter Materials ._ <br /> ........... <br /> Distance to nearest: Well ........ Foundation Property Llne .......................•. <br /> �- SEEPAGE PIT { { Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No i <br /> Water Table Depth Rock Size <br /> Distance to nearest: Well ...Foundation ....... Prop. line <br /> t. � <br /> �. REPAIR/ADDITION{Prov. Sanitation Permit# .......................................... Date .................................. <br /> ) <br /> :. Septic Tank (Specify Requirements) ................ ....................... ........................................................._..............._................. <br /> Disposal Field (Specify Requirements) ..................................................................................................................__............... <br /> . <br /> ................................................... ._... ...... ........................................................................................I...........--••--•• <br /> .................................................. ) .. •-----................: ..... ....-••---...------._.... .............................._..---• ' <br /> r (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with Sara Jeequin <br /> County Ordinances, State Laws,)and Rules and Regulations of the San Joaquin Local Health District. Ham* owner or licen- <br /> sed agents signatum certifies the following: <br /> "I certify that In the performance of the work for which this permit is issued, I shall not employ any patten In such manner <br /> as to become subject to Work ma 's Compensation laws of California." <br /> i Signed ... t -..... . Owner <br /> 8 ............ ............... ........... ........................... .............•......... litle ..__................................._..........................-•...... <br /> i (If other than ownod <br /> I <br /> FOk DEP"ENT US ONLY <br /> APPLICATION ACCEPTED 8Y .. .. <br /> ...... DATE ... a..: ,00............. <br /> BUILDINGPERMIT ISSUED ... .. .......... ...............................................................................DATE ...........................:........:....... <br /> ADDIS N EN S� ..�.......... .... ...... ,.............. <br /> .�tru:......s�..... ......... . <br /> ........................................................ ......................... .-- ....--------...................................--.-•........ ........................................ ........... <br /> ....XVV'-A6....................... <br /> Final Inspection by: .. Date .:............ <br /> .. ........... ........ <br /> ............ <br /> EH 13 2!s 1-68 Rov. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />