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FO's OFFICE USE: <br /> APPLICATION FOR SAkiAkIiON PERMIT <br />- -------- ------- --------------------------------- <br /> (Complete in Triplicate) Permit No, <br /> --- This Permit Expires 1 Year From Date Issued Date Issued _ ................ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549jand existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION{.---------/_ e -------- of -- --------------------CENSUS TRACT `----------------------- <br /> OwnerOwner's <br /> 's Name ------ ---- -l------ / ------------------------------------------------------------ -------------------Phone <br /> Address --------------- �� ��'`5 -------------------------- ---- ------- City x--------------------------------------- <br /> Contractor's Name ----. E"---------------------------------------------------- --------License # ---------:-------------- Phone -- ------------------------•-- <br /> Installation will serve: Residence Afl Apartment House ❑ Commercial [-]Trailer Court !❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:-- ----- Number of bedrooms __�-----Garbage Grinder ------------ Lot Size ` ' -.'___________________....... <br /> Water Supply: Public System and name --------------------------------•----------------------------------------------------------------• ------------Private,rj <br /> Character of soil to a depth of 3 feet: Sand-'E] . Silt E] :. Clay ❑ Peat,❑ Sandy,Loam.❑ Clay Loam ❑ <br /> Hardpan El � #IalAdobe ill M ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in r ti wells, buildings, etc. must be placed on reverse sides) <br /> NEW INSTALLATION: (No septic tank or seepage pit tied if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size- <br /> [ Liquid Depth - -------•---•-•------- <br /> Capacity .�!_ ----- T p ----------- __7C'aferial--- '�r_'_ No. Compartments <br /> " <br /> Distance to nearest: rqe________________________Foundation _.l q_----------- prop. Line __. ,----------- <br /> a <br /> LEACHING LINE No, of Lines ___Il _________ Length of each line----_ ............ Total Length ,. �_'______________ <br /> p _..Depth Filter Material ____�_�'__'.------------------------ <br /> 'D' Box --'----___.-- a Filter Material �-__�1__'__-- --•---- <br /> D' nce to ea est: Well ____ q"____ Foundation ---- <br /> ------------------- Property Line __0------------------- <br /> [, �" _ Rock Filled Yes,0 No <br /> SEEPAGE PIT e h �_._-___ Diameter :��__________ Number ____�'.__.._____.____._ 0 <br /> ater To I epth -�------------------------------------Rock Size "� ----- <br /> - <br /> istance o nearest: Well ------ --------------Foundation -------- Prop. Line -�7+-_________-_-__ <br /> REPAIR/ADDITION(Prev. anitati n Permit# -------- ----------------------------------- Date _____----_-__-__-_-______.__-__.__) <br /> E <br /> SepticTank (Specify Re uire nts) ------------------- ---------------------------------------------------------------------------------------- -•-----------------•-------- <br /> DisposalField {Specify e irements) --------------•-,-------------------------------------------------------------------------------------- ---------------------------- <br /> 1 <br /> ___________________________________________________________________________________________________________________________________.___._-_.___-_--_-----_-----------___-_-._._-_-.-__-_--__________._---_- <br /> ` (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 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 perform nce of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to"become subject to Wo m 's Con0ensation laws of California." <br /> Signed ✓" ------------ Owner <br /> By - ------------------------------------------------------ ------- Title --- ------------------ r <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY p <br /> APPLICATION ACCEPTED BY ---1_2 --------------------------------------------------------- DATE ff ---------- <br /> BUILDING PERMIT ISSUED --------------------- ----------- ------------ ------ ----------- <br /> . ---------------------------- <br /> DATE ------ <br /> ADDITIONAL COMMENTS --------- <br /> 5 ------- <br /> = .-r �' - : -- �_`-' `"7_ _--�------_-------- ------------------------------ <br /> ------------------------------ <br /> --- <br /> p ction by: . �J.a�r��. -------------------------------- '� Date <br /> ---------------------- <br /> Final Ins e 3 <br /> SAN JOAQUIN LOCAL .HEALTH DISTRICT Cj`�/d/1 I <br />,� E. H. 9 1-'68 Rev. 5M ' <br />