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FOR OFFICE USE: <br /> APPUCATION FOR sA P�uarr <br /> (Comp"M Trlpiicatel <br /> Permit No. _ <br /> .......................... This Permit Expires ! Yew From Daft ksmW Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Instatl the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rule�,9nd Rpgulo�tio <br /> JOB ADDRESS/LOCATION ........C,. .11 G� 1........ 0 -TRACT ...M......._..�- <br /> Owner's Name .......A.�..l .!-. 5.1. 2- phone — 01%l <br /> p � ,..... <br /> Address -.. .�.. -..S r... �1( Iii I.V..lA�1/� ........... ....City <br /> Contractor's Name .....s,S.4:h!1....................................................................License# ........................ Phone ..................... _ <br /> Installation will serve: Residence❑Apartment House I-] Commercial❑Traller Court 0 <br /> Motel❑Other............................................ <br /> Number of living units:............ Number of bedrooms _.._........Garbose Grinder ............ Lot Size _.._.___•_____.____-______•...._. .......... <br /> Water Supply: Public System and name -•..............................._......................_.__._.._........__.._......._...____________._____Private❑. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam❑ Clay Loam ❑ <br /> Hardpan❑ Adobe❑ Fill Moteriaf............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, WMIngs, etc. must be placed on revere side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ 7 SEPTIC TANK ------------------------------------------- Liquid Depth .......................... <br /> Capacity Type Material______________________ No. Compartments -__------_____-_..__ <br /> Distance to nearest: Well ............. ..._..__...._ Prop. Une <br /> --•--------------------Fou <br /> LEACHING LINE No. of Lines ......,l../.............. Length of each line....... Total length ..- _•r/ <br /> D' Box .-..�--- Type Filter Ma iol ,A.. _.z.De th Fitter Material .. <br /> ��v�ra� Sam y <br /> Distance to nearest: Well ........................ Foundation Property Line ... ..:............ <br /> SEEPAGE PIT [ ) Depth -------------------- Ok r*W ................ Number ............................ Rode Filled Yes ❑ No C . <br /> WaterTable Depth ................................................Rode Size •-_------•-••-•-•••---•-•------- <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ---------------•--_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........................................... Date ..................................) IT <br /> SepticTank (Specify Requirements) .......................................................__...-_....._......_..___.....__-_...__-_..._-......__....7�, <br /> DisposalField (Specify Requirements) ...................................... •._...-•---•--•--••••••••••.....••-•---...._._............-••-•-__...._.__.._._.....___...._._. <br /> --•-----•---••-•-- ............ .......-........... -----•-- ••--••-•-•---••--•-••......................••-•.__-•-•-••--------•----•--- -------------------•--••-•-••-•-- <br /> .............................. ............................................ ------•.....................-............................................................................................ <br /> (Draw existing and required addition on reverse sidel <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 fhe San Joaquin Local Hoath.DUMB.Nom owner e< [Icm <br /> sed ogents signature certifles the following: <br /> "I certify that in the performance of the work for which this permlt is issued, 1 shall not employ any person In such manner <br /> as <br /> ome subject to Workman's Compensation laws of California." <br /> Sign . <br /> --y- - - --------•- -- •.............................. Owner <br /> By -.......................... ---- ----------•----------------------------••----••-- ............___- Zitle ........ ............................-.......................---.._.. t <br /> (If other than owner) <br /> FJA DEPARIM USE ONLY <br /> r APPLICATION ACCEPTED BY ..._Gs .... ................ ....-....... ---__.._................... DATE .....' .77,;2-/. .. ._._.. <br /> BUILDING PERMIT ISSUED ... •......................•-- .-.....••--------- DATE . .......-.... <br /> ADDITIONAL COMMENTS ............... <br /> ................ .................................. <br /> ...............•... ......................... <br /> -------- <br /> --------------------------------- <br /> -- .......*---- - ------*-------- <br /> ... ._.......... v — <br /> --**....... . <br /> ..__. ^� �;.. <br /> Final Inspection by: . Dote .. ....... ... <br /> Fi13 2t� 1-68 ----. --- ----•••••-••........ ........•-•-- -••-•••........ _-............. .._. .... ...._............. <br /> v• 5H SAN JOA UIN LOCAL HEALTH DISTRICT 8/7w 3M <br />