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--- <br /> 4 (Complete in Triplicate) Permit No. <br /> ----------------­--------------------------------- <br /> L�i �. . <br /> = This Permit Expires f Year From Date Issued Date Issued <br /> FApplication is hereby made to the San Joaquin Local Health District for a permit to construct and Install the <br /> �, described. This application is made in compliance with County Ordinance No. 549 and ex€sting Rules and Re work ulat€onsein <br /> JOS ADDRESS/LOCATION ... /Jn�3--_._s-.. , ,,� // <br /> ..Y.F.. -- -- J CENSUS TRACT <br /> Owner's Name �i�If !- t? `.._..._... ..: �•!- <br /> Address . f .. <br /> r �} <br /> auk r Name -- .`fY-�-- - __/ .---:----�V City !'"1.�.>!t�..��.�� _ <br /> ----.�=_. _ .=� .......---...License # ........:.......... <br /> Installation will serve: Phone .................. <br /> Residence-'KA House fl Commercial QTroller Court 0 <br /> C Motel ❑Other_.. <br /> Number of living units------------- Number of bedrooms -Garbage Grinder ------------ Lot Size .... <br /> Water Supply: Public System and name .--------------- <br /> .y: y <br /> Character of soil to a depth of 3.feet:F0 Sand b Silt❑ Clay ❑ Peat❑ Sandy Loom WClay Loam Q <br /> Hardpan ❑ Adobe fl Fill Material ............ If yes, type <br /> (Plot plan, showing size of Int, 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 <br /> PACKAGE TREATMENT within 200 feet,) <br /> I � SEPTIC TANK{ � Size------------------......................._._.. Liquid. Depth ....•-----...---••---.. ..'� <br /> # _ _ <br /> Capacity j- � Type MaterialVt. `No. Compartments �. . d <br /> Distance. to nearest: Well _.__f©, -'-••-----------•----Foundation --./.0-`-.. .. Line ../&P.'f IN <br /> LEACHING LINE Prop. ....-__-. <br /> [ ] No, of Lines C <br /> . ------------- Length of each 1' e,._•--- Q.-----. .-•---- Total Length g;!..7 <br /> � r <br /> g .............. <br /> i 'D' Box ... <br /> Type Filter Material JzPiA _Depth .Filter Material <br /> Distance to nearest: Wel! -.I. �-'._.-_-- -• Foundation j G'� ' <br /> - ��-� Property Line . .. <br /> SEEPAGE PIT - -•.................'� <br /> I ) Depth -------------------- Diameter ----------------- Number -----••---------- .......... Rock Filled Yes No C];, <br /> Water Table Depth ------------•---- •---- <br /> -----------------------Rock Size ----------------- .............. JIM. <br /> Distance to nearest: Well ............ o <br /> •• <br /> Rfrl'Allt/ADDITION(Prev. Sanitation Permit# ---------------- - <br /> F! --------- ....... ------ ------------ Prop. Line .......................I <br /> - -•- - DI � <br /> -------•-----_--- ate -----•-- <br /> Septic Tank (Specify Requirements) --------------- <br /> FDisposal Field (Specify Requirements) ---------- --- <br /> - ------------------------------------------------------------ <br /> ---------------------------------- --------------------------------------------------­-----------I—,.......... <br /> ------------------------------------- ----------- ­------------------------- --------------- ---------------- ........ -------------- ......... <br /> F <br /> ---------------•-------- ------ ------- ------. -------------------------- ................................ <br /> --- <br /> raw 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 San Jaagvin <br /> F, 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 performance of the work for'which this permit is issued, I shall not employ any person In such manner <br /> as to becornsubject to Workman's mpensation laws of California." <br /> FitSigned __ f' i` `�� ° <br /> ^ --.'.-_d�- -- t--- - Owner <br /> By - -- ---- <br /> -------------------- - ---- Title --------- <br /> i other than owner) .......... ........ - .. ----- <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BYy. � <br /> 13i1ft bING PERMfT ISSUED ------ --- <br /> - - 1 �•-- ----------- .--- DATE ... <br /> ADDITIONAL COMMENTS --------- ------ .-- - f- <br /> ----------- - - - G <br /> S` _...� - <br /> ----------------------- ---------------------------- ---------------------------- ------------- -------- <br /> - <br /> Final Inspection by: .. . _ <br /> ---------------:------------- bate - ~..._ 1 - II <br /> �- E1"I �.3 21� I-bf3 Irv, �---- - �- - - <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r^l <br /> 8/7!t 3M <br /> t <br />