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• <br /> F <br /> FOR OFFICE USE: <br /> APPLICATION FOR ,AN1. TION PERMIT ��3l <br /> 7� ' ,� Permit No. - - --------------- .-.� <br /> --------------------- <br /> -------- --------- <br /> YT---------------- -- -------------- (Complete in Triplicate) <br /> __ . .... <br />-----=-- - - ssued <br /> ------- ---------_-- This Permit Expires 1 Year From Date Issued Date I <br /> Applicationis hereby made to the San Joaquin Local Health District.:for ❑ permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules aril Regulations: <br /> i <br /> JOB ADDRESS/LOCATION �� CENSUS TRACT <br /> � �/�.. Phone = -------------- <br /> Owner's Name - -4��/71 4 L, �� <br /> - nse ' <br /> Address ------- � '�/--;--------------------------------------------------------- <br /> ---- - -- <br /> -----°------ -------------- ------------ ------------ City -� _� '�'• ----------- <br /> Contractor's Name ----- rte rlrl;;w- -------------Lice #� ,1 ,��.-- Phone <br /> Installation will serve: Residence Apartment Housd'❑ Commercial ❑Trailer Court ',❑ " <br /> -Motel ❑ Other ---------------=----------------•--------- <br /> Number of living units:-_----- Number of bedrooms -------Garbage Grinder/ --__ Lot,.Size --t - ---�- � <br /> f_ Or ------ -----Private ❑ <br /> Water Supply: Public System and name ---e-AV "------L��t���s <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑` Cldy ©�+-Peat❑ Sandy Loam 0 Clay Loam El <br /> Hardpan ❑ Adobe�'MleFill 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 TANK f ] Size-----------------------------------•---------- - Liquid'Depth'-------------------------- >N <br /> ' e:nts <br /> Capacity -------------- - Type -------------------- Material---------------------- No. Cornpartmv�. <br /> 1 ; <br /> Distance to `nearest: Well ------------------------------------Foundation ----- ------ Prop.'Line -------------- <br /> at <br /> LEACHING LINE [ ] No. -of Line's-------------------------- Length of each line---------------------.----- Total Length `-----------I---------------- <br /> 'D' Box -----1------ Type Filter Material --------------------Depth Filter Material -------------------------------•------•- r <br /> Distance to nearest: Well ------------------------ Foundation ----------------------- Property Line- -------------_-------- <br /> SEEPAGE PIT [ ] Depth ------I------------- Diameter ________________ Number ---------------------------- Rock Filled.- Yes F] k Noy` <br /> ---------------Rock Size --------------------------------- <br /> Distance <br /> ---------- ------ - �+ <br /> Water Table Depth --------- } ' <br /> -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------2tt---=------- <br /> REPAIR/ADDITION(Prev. Sanitation 'Permit# -------------------------------------------- <br /> - Gbate -------------. --------------------) R_..-----------=---e-----r-r-- <br /> -----«--.-� <br /> - <br /> Septic Tank (Specify Requirements) ------------- -- - ,- --------�-z �-:-.z+ <br /> Disposal Field (Specify Requirements) ------ - ' ----```Trr! / `v <br /> ----------------------------------------- ----------------------- < <br /> I <br /> (Draw existing and required addition on reverse side <br /> -1 hereby certify that I have prepared this application and that the work will beclone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeowner 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." 3 <br /> Signed __. {!----Owner <br /> --------- -------- ---- <br /> BTitle ----- - ------------------------------ <br /> Y ------------------------------- -- - '' r, r <br /> r (If otheef an owner) R 4. , <br /> FO _ PARTMENT ,USE ONLY <br /> ,.� Cyt <br /> -APPLICATION ACCEPTED BY ---- -- -------- -------------------- :----------------- ----- DATE --'4 1. { <br /> BUILDING PERMIT ISSUED ------- ---- /-T---a," DATE <br /> ADDITIONAL COMMENTS --------------------------------------------------- <br /> ---—- ---------- <br /> ---------- -------------------------------------------------- ---- <br /> -------------- <br /> ------------------------------------------------------------------------ -- -------------------------------------------------------------------------------------------------------- <br /> - ------- <br /> ---------------------------------------------------- --------------------------=-------------------- <br /> Final <br /> ----------------- ! pt <br /> Final Ins ection b z _t_ -----------------------D e - ----r------------------------ <br /> JOAQUIN LOCAL HEALTH` DISTRICT <br /> t <br /> E. H. 9 1-'68 Rev. 5M <br />