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!� <br /> FOR OFFICE USE: ��---------- <br /> ---------------------- AAP ICATIO NITATION PERMIT FOR OFFICE USE: <br /> ------------------------------ -- -------------- [� Q lete in Trip teJ <br /> Permit No.. <br /> 1 -- - � <br /> This Perini it 1 Year F Date Issued---�` <br /> Date Issued <br /> Application is hereby made to the San Jopquir;�LocaLHealthkDistrict for a permit to cons qn <br /> This application is made in compliance with County Ordinance;No, 549% and ex' <br /> - d instal the work herein described. <br /> _� , istingRules arid'Regulations: <br /> J DDRESS/LOCATION- F f -` - -� # <br /> wner's Name.__� � - <br /> --..----- CEN ---------------- <br /> - SUS TRACT--------------------------------- <br /> Address-­ <br /> " <br /> dress -=-- -- . # <br /> -- -- -- ---• -- - --------- -- -----------------------P ane <br /> Contractor's Name------ _ --_.-----; ------1. --------- ----- - -- - -- <br /> C'ty <br /> - - zip <br /> /« -------------------- <br /> Installation will serve: - .- - -----------License # 1 <br /> Residence — 1. � -._Phone__" c ! D ; <br /> ❑ : A artment House_ � -- ---T-�f- - - <br /> r Motel ❑ Commercial 0 "`Trailer Court❑ <br /> Other <br /> Number of living units:---. --- <br /> _.___---_ <br /> -- ---- --- <br /> Number_of bedrooms-_-- ---Garbage Grinder•-_- -_- "_Lot'Size__.-__ <br /> Water Supply: Publi System ak Ind name. ---.---- <br /> -------------------------------- ------ <br /> Character of soil to a;depth of 3 feet: ; Sand [) Silo " - P <br /> i❑ Clay ' ----- rivate'Fk <br /> t Y ❑ Peat❑ Sandy Loam <br /> Hardpan ❑ Ad' ❑ Clay Loam ❑ <br /> 3 1 If Yes, type <br /> obe ❑ Fill Materia <br /> (Plot plan, showing size of lot, location of system in relation to''wells, buildings, etc. must be placed on rev ' <br /> NEW INSTALLATION( (No`septic tank or see <br /> page p g pit permitted if public sewer is available within 200 feet]1d <br /> e.] <br /> PACKAGE TREATMENT [�] � SEPTIC TANK -[:] �: - t <br /> Ga acit <br /> Size- <br /> -Type S1 ----------------------------------------------------------Liquid p <br /> P - h----------- <br /> --------------- <br /> to <br /> ze <br /> -- ---- - -- �-- ----Material---�= -'-="- - ---- �--- �-- <br /> ' # .... ...N Co p rtment ------ -------- <br /> nearest:to nearest:Well-_..-° • - No.'Compartments a s j t <br /> LEACHING LINE I y] No t <br /> .-. ist , <br /> " Length of each line. Prop. Line_, <br /> _ Foundation._ <br /> of Lines_ t <br /> " ype Filter Material__--_ <br /> D Box . T Total Length _ _ <br /> Depth Filter Material_---------- " <br /> Distance to y ° -- ---- <br /> neorest: (Nell- !_._ <br /> - J. -------- Foundation_._. Pr T 7 <br /> SEEPAGE PIT " ' <br /> [ l Depth -------- ----Diameter-`---.` Num ---------------------------- <br /> t -- ------- <br /> Property Line <br /> Water Tabie'D- <br /> „ . <br /> eptly =----- ... ------------------------... Rock Filled <br /> Yes ❑ No <br /> -------° - c <br /> R !ed <br /> Size ---------- ---- -------------- <br /> ----- - -------- - Foundofiori__:: __ ,�a <br /> :..Prop. Line----------------- <br /> 1s ance;to nearest;Well.� _"__:"'� -_"; , ,; { "--"--"'- <br /> REPAIR/ADDITION {Prey. Sanitation~Permit# ____-"_-"_-.._-_ <br /> : Date <br /> a <br /> ------- <br /> Septic Tank (Specify Requirements)_..__:_._ f ]' <br /> t <br /> Disposal Field (SpeC3fy Requirements] _ ;--------- ----: _ <br /> r <br /> l <br /> ® _ p -.. <br /> ----------- }"` <br /> .. . -------------------------- ----------- _ <br /> 9 <br /> E (Draw existing 'and required addition on reverse side) <br /> I hereby certify that i have-prepared 'this application and that the work will be done in accordance-with Sar Joa uin^Cou <br /> Ordinances,- State Laws,and Rules and Regulations of; the San Joaquin e ownerlor licensed a e <br /> signature certifies the following: n Local Health DistrictHome q my <br /> g nts ! <br />"I cert( that in -thel <br /> f,Y, � perforMarice- of:the_work for"which this permit is issued, 1 shall not em to any ` 1 <br />'o become subject tozWonkman'sTCompensation�-lawsrof-California.., - - �.�: _ ,, p y y Person 'in such man er as <br />>igned__ "`'fit s : __ .;__g�, �._,.j <br /> r Owner <br /> f(If p er fhan`owner) .. <br /> Title -------- <br /> ,. --- ----- --•---- <br /> # FOR DEPARTMENT USE ONLY' M. t <br />�PPL1CATiQN ACCEPTED BY`_- <br /> - ----------------- <br />)IVISION OF LAND NUMBER------------- ' <br /> -- - ----- - DATE.- <br />�DDITIONAL COMMENTS_. - ................. { <br /> ;.DATE <br /> � 1 <br /> = ------ - <br /> .- ----- - <br /> ----•---- <br /> ----. _----- -`---- ------- <br /> ---------- - <br /> na1 Inspection b „ <br /> f ---------------------- <br /> 18 24 <br /> --------------- --- " .�� <br /> Date.- -�w = <br /> SAN.JOAQUIN LOCAL HEALTH DISTRICT <br /> F&S 21677 REV. 7/76 3M , <br />