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FOR OFFICE USE:S P POR PERMIT <br /> APPLICATION 6_t7f <br /> �01-------- Permit No. <br /> ------------------------ (Complete in Triplicate) <br /> ----------- -------------------_V-------------------- Date Issue( <br /> This Permit Expires 1 Year From Date Issued <br /> 7--- ------------ ------------------------------------ <br /> Application is hereby made to the San Joaquin Local Health District for a permit <br /> mit to construct and install the work herein <br /> 0 <br /> described. This application li)macle'in compliance with County Ordinance No. 549 and existing Rules and Regu1tionS. <br /> ON ---- -- --- ------ ----------- <br /> JOB ADDRESS/LOCA1 - --- --- -- --------------CENSUS TRACT -------------------------- <br /> zt <br /> -------------Phone ------------------------------------ <br /> Owner's Name ---- - ------- <br /> -7 Cit,- --—----------- ---------------------------------I-------------- -------- <br /> Address ------------- rise <br /> Lice Phone,�;e <br /> Contractor's Name ------- <br /> --------------------------------- <br /> ❑ <br /> Installation will server L Residence F1 Apartment House,[] Commercial'13Traile Court <br /> Motel F-1 Other --------------------------- ---------------- <br /> ------------_ <br /> Number of living units:--:---___--- Number of bedrooms -_----_----_Garbage Grinder ------------ Lot Size <br /> Water Supply: PublicSy em and name ---------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth X of 3 feet: Sand'E] Clay 0 Peat F❑-1 E]SiltF Sandy Loam -0 Clay Loam, <br /> I <br /> Hardpan M ­ 'Aclobe` ill M dife f i a If Yes, type ---------------------------- <br /> - 3�_fil M <br /> (Plot plan, showing -size of' lot, location of, system in relation ta wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:"'( feet,) <br /> septic tank or seepage pit permitted if public sewer is available within 200 feet <br /> 4� <br /> PACKAGE TREATMENT J-1 SEPTIC TANK{ I Size---------------------------------------- ------- Liquid ----------- -------- <br /> No. Compartments -------- ------ <br /> Capacity -------------------- Type -------------------- Material-------- ------------- <br /> 'Distance to nearest. Well ------------------------------------Foundation ------------------ Prop. Line ---_---•-- ------ <br /> V Length ----------------- <br /> LEACH I t4O/LINE No. of Lines ------------------------ Length of each line---------------------------- Total Leng ----------- <br /> pth Filter Material ---------------------------- -------------- <br /> 'D'. Box -------- Type Filter Material --------------------De <br /> Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line. ------------------------ <br /> t SEEPAGE PIT- Dep --Depth ----- -- --------- Diameter ---------------- Number _..------------------------ Rock Filled Yes El No 0 <br /> WaterTable Depth ------------------------- ------------- --------Rock Size --------------------------------- <br /> Distance to:nearest; Well ----------------------------------------Foundation -------------------- Prop. Line ----------- .......... <br /> REPAIR/ADDITION(Prev.ILanitc�fiion Perm it# -------------------------------------------- Date ------------------ <br /> ---------------- <br /> ----------------------- ------------------------- <br /> 4u <br /> Septic Tank (Specify Requirements) --------------------------------- ---------------------------- .1 <br /> _X�;------------- <br /> Disposal Field (Specify IF Uilrements) - ------ - - - ------ --------- <br /> r <br /> - ---------- -------- ---- ---------- <br /> ------------ -------- -------------------------------- <br /> 4......... Z- eJr­StA1------Z04 <br /> --- ------- ---------- <br /> (Draw - ,-,ina d required ad ition on re i <br /> .. de) nce with Son Joaquin <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Home owner .r licen- <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District a <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 become subject to Workman's Compensation laws of California." <br /> -------- Owner <br /> oa Signed ------------------------------ -------- #I <br /> Title ------- <br /> By ----------- ---------------- ------ <br /> (if other n owner) <br /> Pa <br /> I F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- -- ----------I-- ------------------------------------------ DATE ---d-7 /- -------------------- <br /> BUILDINGPERMIT ISSUED --------- - - --- ----- --------- -----------?#----------------------- ---------=--------------DATE ------------------------ ------------ ----- <br /> ADDITIONAL COMMENTS ------------- --------- ----------------------------------------------------------------------------- <br /> . I A- -: .. I - ----- 4 JA ---------------- ----------------- <br /> - -- ------------ - - <br /> ----- ------------------ -----------T_�Pr--------------- -- --------------------------------------------- --- <br /> It -------------------------------------------------------------------- ---------------- <br /> - - --------------- <br /> ---------------- -4 <br /> ----- ------------ -------- ------------------------------------------ - ____ - <br /> r--- <br /> -- --- -- ---------------------------- - ----- - I-------------------- Date .---------------- <br /> --------------------- <br /> - <br /> Final Inspection by- --- ------ <br /> E. H. 9 1-'b8 Rev. 5M. <br />