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FOR OFFICE USE: APPLICATION •I:®R`SAi�Pf'i�CIT �PERMIT , . <br /> .........I.................------•---•--•-•-•----------. ' Permit No. vi:7. 7... <br /> (Complete in Triplicate) <br /> .............................................. *-:4 <br /> Date Issued ...`,�._.l : <br /> b- . t This Permit Expires 1 Year From Date Issued <br /> Application is by a to the San Joaquin Local Health Disfr� or-:e permit to construct and Install the work herein <br /> desyri�e is ,plicYi {r?1 co� rrste with County Ordinance No. 549 and.existing Rules and Regulations: ' <br /> JOB <br /> �p ADR SS/LdfCATION d3 ��•-- - :� _..._/1./�'• IS TRAC ._.._... ......_... <br /> Id ��� 1 <br /> Owner's Name •--------- IT _c5 ... .. .} E` :._..------••----------------•----= •-•-•--•-•- ......Phone <br /> Address -•---•------(c 10job s-- ...... -R ................city ..........._.. .. •--- --------------- <br /> /. _ _ •--- --• ,---•---.License#( d . Pone <br /> Contractor's Name . . . ______ __ __• �$ <br /> Installation will serve: Residence tgApartment Housel-] Commercial:QTrailer Court 0 <br /> 1------- Garbage Grinder <br /> Motel❑Other----------- ------ ......................... �. Q <br /> • Number of living units:._. Number of bedrooms ._._.._ g 411P..... Lot Size ___ ......... <br /> Water Supply: Public System and name .......................................................-.-......_.............................. <br /> ..... <br /> ......Private <br /> .. - <br /> -�-rCharacteT-of-soil-to'a depth-of3'feQt:'�SdnifV-^�'Silt❑ 'flay []�Peat"Q���r-`Sandy�t'oam�] ��Cl�loam�"'r'�"""`—'`-"�. <br /> Hardpan EQ Adobe}] Fill Material ..l.R.+�..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 /> NEIN INSTALLATION: (No septic tank or seeps pit permitted if public sewer is available within 200 feet,) <br /> i `r <br /> PACKAGE TREATMENT [ I SEPTIC TANK• Size.__ __.Y...467Y...Z ______- Liquid Depth ...� -------- <br /> Capacity -C!5�-0---- Type` 1 Material�p �o. Compartments ..X.........:.... <br /> stance to nearest: Well Z_C .....................Foundation .._.l 0!....... Prop. Line...iS_f............ <br /> LEACHING LINE [ No. of Lines ------1Z LengthkZk <br /> h line......... Total Length .._.�..5 ........... <br /> 'D' Boxya5Type Filter Material -.-Depth Filter Material _--•7,7..Q...♦................•............. <br /> .I - o <br /> Distance to nearest: Well ...._.6 --___-•• Foundation _.._.Z.�________.. Property Line. _-�.................. <br /> SEEPAGE PIT [ ] Depth Diameter ................ Number ............................ Rock Filled Yes 'Q No 0 <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest; Well........................................Foundation .............. Prop. Line _..........__........ <br /> i <br /> REPAIVADDITION(Prev. Sanitation Permit# ............................................. Date ............................ <br /> r <br /> SepticTank (Specify Requirements) _.....--•-•------•-----••--•-----------•...:........................•----•--•-••---._...-•--...__•-........._..,...__......--..------...... <br /> DisposalField (Specify Requirements) -----••-----------•-•----------------•-•-•---------- .................................---------••--_-----......................... <br /> --•----------------------------- ...•• t <br /> (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 San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Home owner or liren- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." u <br /> Signed - 4 Owner <br /> By .......... . . :- ..- ----•- - --------------•- ---- <br /> Title -_----------• ---------- <br /> • <br /> (If other thane owner} I - ' <br /> k <br /> ! FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY....._.-1'i. ......................•--•--•-•-•-•-•-•---•---•--. DATE ........ `_' <br /> BUILDING PERMIT ISSUED .......... ... ------... ._....•--- <br /> •-� -------------------------------•---..._... _._-----•---•--....--------:....._._..._..DATE ._....__.........._. ' <br /> ADDITIONAL COMMENTS 1: ------ - <br /> r <br /> ...---------------.....-----•-••------ --•••---. <br /> ;; <br /> - - = -••.............•. <br /> Final In ection by: - .Zc.................. ..Date------- -....... ... <br /> SAN JOAQUIN LOCAL HEALTWPISTRICT <br /> E. H. 9 T-'68 Rev.3M. t <br /> y. ' <br />