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jir 11V1V rVK SAmijAIIVN rCKMIT T <br /> ........................................................ <br /> Permit No. . C.`lI.... <br /> (Complete In Triplicate) <br /> ........-•............................................ <br /> -- -•-- ---- This Penult Expires t Year from Date Issued Date Issued . .................L <br /> E Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the ,work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> -S � 33 t ? / <br /> JOB ADDRESS/LOCATI N ��1 z� .Y� .__.�` - .............`�C�NCUS TRACE' <br /> ...--................. ...•-• ..._..._. <br /> Owner's Name ..--IV--_. _lJz,Q /3 . ........Phone <br /> .................................... <br /> E - - <br /> 4 Address -.._.. -----•-------------•---- ....................... -----------....._i_...:............:City .... r f.. <br /> .� <br /> f <br /> Contractor's Name cd�f�.'��� . --..--•........................License # ..��'�...... Phone ......... <br /> t installation will serve: Residence p Apartment House%Commercial C]Trailer Court JJ <br /> N <br /> Motel [3 Other •---------------------------------------••-- <br /> t <br /> l <br /> Number of living units=------------ Number of bedrooms ----........Garbage Grinder ............ Lot Size f.6 _.x._ ............ <br /> I. Water Supply: Public System and name .........................................................--..................................................Private <br /> Character of soil to a depth of 3 feet: Sand o Silt o Ciay p . Peat❑ Sandy Imam o. Clay Loam Q <br /> r <br /> : Hardpan p Adobe 0 Fill Material ............ If yes,type............... ............ <br /> ]Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.], <br /> NEW INSTALLATION: (No septic tank or seepage pit ;permitted if public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANX ] Size_ . ........ Liquid D h .. <br /> Capacity�b. - -.-__ Type ...... . Materia!_ No. Compartments . ............. <br /> Distance.to nearest: Well --------� �..---......Foundation ...� ........... Prop. line ..,�................. <br /> LEACHING LINE ( ] No. of Lines ....../......--------- Length of each line.------s ... Total Length ....S_S, .. ....... <br /> f. <br /> 'D' Box ./.._...... Type Filter Material I .........De.pth Filter Material .�1...--. �-��- <br /> Distance to nearest: Well ........................ Foundation ------.-------------.... Property Line ........................ <br /> i SEEPAGE PIT [ ] Depth -------------------- Diameter ................ Number -------_------ ----_-----. Rock Filled Yes [] No 0 <br /> t 9'Water Table Depth --------- •.............•----.................Rock Size -............................... <br /> Distance to nearest: Well ......................foundation .................... Prop. Line ..-_--_. ............. <br /> ( } <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................................... Date .----------------------------_----- <br /> SepticTank (Specify Requirements) ...........................................-------.............................. ------------------------------ _......._................. <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------•--•----- ----------------•--- .......... <br /> ----------------------------------------------- • ----------- ----------------­---------........... ---•--..... . .........................._.._.................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that f 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:Dlstrict. Home owner or <br /> licen-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." l� <br /> E Jam/ y`V <br /> Signed --------• -----------------------------------•-- ------------ ---------------------------------- Owner ivy 1Vl' <br /> By ----------------------------------------------.._-.-------------------------------- ----•-------I----- Titte ----------- <br /> (if other than owner) <br /> FQR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 'BY _ _ -- .. ..... DATE <br /> i ADILNG DIDTIIONAL COMMENTS N75 DATE ------ . -- <br /> I — ccREc. _....._..... -•----.----- <br /> k --- -------------- - ---- -•---------•- --------- <br /> .-.-•- ------ ---•---- •---•--------------------------------•---- <br /> .. = 7..'. <br /> --------------------- --- <br /> Final Inspection by: -•--------- --- ----_-------- - ..._..--- ------.Date �. .--�_V�_ ....... <br /> ' <br /> Ell 13 21a 1-68 herr. 5M AN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> I ,� <br />