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e+r"rryra.ArrVrrt rVK bAMjjAjjVrj lri"IfMIT <br /> ..................+................................ ... (Complete 1n Triplicate} Permit No. ..7�: ..3 � <br /> .......... "� Date Issued ...` .:�G <br /> ................................. This Permit Expires t Year From 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 /> dcsuibed. This application Is made In compliance with County.Ordinance No. 549 and existing Rules and Regulationso. <br /> �o ADDRESS/LOCATIONRACT <br /> l a - <br /> .................CENSUS T ....................... . <br /> Owner's Name . ... `, Phone <br /> Address .................... _. � ........ ---._..._.....,...... .,��..............._............. ...... .......................... <br /> Contractor's Name . �� .__......-..Eicense ...Phone4' '..a' � <br /> ;i A0 ..................... .. <br /> Installation will serve: Residence❑Apartment House[] Commercial[]Trailer Court 0 <br /> Motel❑Other <br /> Nurnber of living units.....:...... Number of bedrooms - .---------Garbage Grinder ............ Lot Size ......------.--............................. . <br /> Water Supply, Public System,and name .Private [� <br /> Character of soil.to a depthaof 3 feet: Sand n....Silt❑ ..`.Clay ❑ Peat 0 Sandy Loam ❑` .Clay Loom 0 <br /> d <br /> Harpan(] <br /> ! Adobe❑ Fill Material ............ If yesE ................. ............ .► <br /> (Plot plan, showing size of lot, Iocatlon of system In relation to wells, buildings, etc. must be placed on reverse side. <br /> NEW INS ALLA <br /> T TION: (No septic tank or seepage pit permitted if public sewer is available within 200#eet,f <br /> i PACKAGE TREATMENT { } SEPTIC TANK[ ] Size.............:...................--=:,.......... Liquid Depth..........................,,J <br /> Capacity Type --- Material <br /> Material......... .......... Na. Compartments .. :........... <br /> ». <br /> #ante to nearest: Well' . <br /> � ll`. ... <br /> E; Dis ......................Foundation .......... Prop. Une ............._ .4E <br /> No <br /> LEACHING LINE [ . of Lines ---------------- Length of each line... .. ............. Total Length .._.............. ... ' <br /> 'D'ilBox ............ Type Filter Material -:. ..Depth filter Material ._ ...........................: . <br /> Distance t4 nearest: Well ........................ Foundation .................. Property Line ...................... - <br /> SEEPAGE PIT f 1 Depth Diameter Number .................... .: Rock filled Yes Q No <br /> Water.Table Depth ...........Rock Size <br /> Distance to nearest: Well ........................................Foundation ..................... Prop. Line ...... <br /> REPAIR/ADDITION(Prov. Sanitation Permit Date <br /> Septic Tank (Specify Requirements! .......:........:._........................ <br /> .. ._... ..... ._.. [ <br /> s ... .............. ..........,........::: ._ ....... _........ .. <br /> ..... <br /> . .�_ <br /> DisposalField (Specify Requirements) ....................•................. --....._.......... .................--............................... .......................... <br /> -� ..........................................................................---•.......................................... .......... ........................I....................... <br /> .............................•-•---•---.................---•----......_..............---•----•...-••--......_..............._......----_.._....---....•.---------- <br /> ..............................:...... <br /> (Draw existing and required addition an reverse side] <br /> I h reby eeertlfy that 1 have prepared this application and that the work will be clone in accordance with Sar► .Joaquin <br /> County Ordinances, State Lpws, and Rules and Regulations of the San Joaquin. Local Health District. Hance owner or 11cen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of.the work for which this permit is.Issued, I shall not employ any person ler such manner <br /> as i*become subjec� Woiikrnon's Compensation laws of California." <br /> Signed Ar <br /> .......... ....•-------•••••....------. = ... :.. Owner <br /> E . <br /> Byi................................................................................... <br /> (If other than owner) <br /> l` R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY•...._...--------•. ,_.�.. -•---•---•....... ........ ..............-. DATE ........ .. .. ,... :T.. ......: <br /> BU11_DING. PERMIT ISSUED-'i- ...................................... <br /> .....DATE _........ ..................:............ <br /> ADDITIONAL COMMENTS • ...-----•-.................. . <br /> .s <br /> ........................ ........ _ _ <br /> ................. . . •-- .q' ---........ ------...._........_.........------...L.-.... ... -----•-. --:.. ................. <br /> -..............._.......... <br /> Fin ----------- _...-- <br /> aI Inspection by: .. ........ <br /> ...............................................................Date __ .,r% <br /> a <br /> .......... <br /> Mi <br /> 113 2a i-6fl '�• ;rte SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 8/7h 3H <br />