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. �■ ■ r■vn■,V■• ■V!� JMI\IIMIIVI\ fGIVYitI <br /> .............................................. <br /> (Complete in Triplicate) Permit No. .............. <br /> ••-•••••.......•...• This Permit Expires I Year From Date Issued Date Issued :-.G. � <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application Is made In compliance with County Ordinance No. 544 and existing Rules and Regulations, <br /> JOB ADDRESS/LOCATION .... --O.-.Z � .. <br /> .CENSUS TRACT <br /> Owner's Nome ......��1:...< .�....�..t.Z. ......................................... ... � .......................... <br /> _ 4 <br /> {_. ............................ Phone ..1I:.L'>.?.C _... <br /> Address _... - ......�..(...��.. � .L - ..... .� .......... <br /> City ...5 - `� �-%. <br /> Contractor's Name `� '-z-c� c�_ ............................................... <br /> --------------------- '...... ... ...........--•.License # �l...:. r_..... Phone � ..:��uQ <br /> Installation will server Residencet ;Aportment House 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other ....... <br /> Number of living units:............ ?dumber of bedrooms ............Garbage Grinder ........ Lot Size .Z.q,! - - <br /> Water Supply: Public System and name ------------------ --- ------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Q Q <br /> Hardpan ❑ Adobe la Fill Material ............ If yes,type............... ............ <br /> EPlot plan, showing size of lot, location of system in relation to wells, <br /> Y buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a,,�it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK ] p t!/n 1� Shze....... .�..s. ......................... liquid Depth ....z./P........... <br /> Capacity .-l.�.0.�......... Type .. ..._... Materlal..C(/.1- —1-e1..... No. Compartments ----... ...._..._. <br /> Distance to nearest: Well ........4 1. (�- <br /> .. .................Foundation ---..... �-------._. Prop. Line ...................... <br /> LEACHING LINE No. of Lines ........ -............ Length of each line.....--.6ALF........ Total Length ..... .Q..�............. <br /> r <br /> D' Box .... ... Type Filter Material -!-':•.....Depth Filter Material ........1 ............. ................ <br /> Distance to nearest: Well ...... ''....... Foundation ..--- f•...... Property Line ....r.:............ <br /> SEEPAGE PITL(IQepth ...-. �_....... Diameter .......>....... Number ............... .......... Rock Filled Yes ' No 0 <br /> Water Table Depth --------------------------------------------Rock Size - .'2.0­14:.",........- i <br /> Distance to nearest: Well ........... ............Foundation ... ..... Prop. Line .._ .............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ........................................... <br /> Disposal Field (Specify Requirements) --...--•................................•...-•--•----.........---.......-•---...--••--.......................................------. <br /> .................-••--... ................................................................................................................................................................................ <br /> ......-•--•.......................................................•----•-•--•----...._......................_.....--------...------------------ --••••--. ............................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Sari 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 become subject to Workman's Compensation laws of California." <br /> Signed ---- ---- ---- -------- , �. Owner <br /> GL <br /> BY .... -------� .. .Title................................ ...................I........... <br /> (If othe an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ._. ... . ./l.` � %........... <br /> 4... DATE .... ....................... <br /> BUILDING PERMIT ISSUED ............. ...... E. ..................... . DATE .. .....-.................................. <br /> ........ - <br /> ADDITiONAL COMMENTS ------------- - -- -- - . _ ✓�!•�..�......�•7... �� <br /> ........ ..--------------------------------•-•--.•--------- '-----....` ....-�..::_....:�.....:�.::....................... ...... ..........'.:........:.::..:.:_:...._......... <br /> . -•-... <br /> �' Final Inspection by: '_ Date ... . .,. ... .. ................ <br /> .. ....................................... .............. <br /> EH 13 2!t 1-68 Rev. 5q'1 SAN JOAQUIN LOCAL HEALTH DISTRICT Ph 3M <br />