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/ FOR OFFICE USE: Q. R SS <br /> APPILICATION FOANITATION PERMIT (� ' <br /> ------------------------------ ------=- <br /> (Complete in Triplicate) Permit No. <br /> ____________ ______ This Permit Expires 1 Year From Date Issued Date Issued _7_-.3-7e , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein a <br /> described. This application is mode,* corn liance County ante 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO I ------------- ------------------------- <br /> TRACT <br /> Owner's Name -------------- one <br /> Address ------------ . . ---------- city <br /> ------------------------- <br /> ---------- ------------•--•-•- <br /> Contractor's <br /> Name -------------K --------------------------------------------------------License <br /> # ------- -------------- Phone ----------------------_------ <br /> Installation <br /> - -------------•-•-----Installation will serve: Residence n-A' partment House❑ Commercial ❑Trailer Court !,0 e # <br /> Motel [] Other -------------------------------------------- `� <br /> Number of living units:------/I_. Number of bedrooms __-*_�-------Garbage Grinder __—.-- Lot Size _` _ '-__ <br /> Water Supply: Public System and name ____________________ --------------------------Private <br /> Character of soil,to a depth of 3 feet: Sand'❑ Silt❑ Clay El Peat E] Sandy Loam E] Clay Loam:❑ <br /> _ _ <br /> Hardpan E] Adobe Gill Material ________ If est" e"—"' - - ' <br /> _�..._ Y YP ----------------------- <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: ( septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [-.Tt SEPTIC TANK' Size.... 1,01 <br /> ___ __________________________ Liquid Depth --- - ------------- <br /> Capacity <br /> r Type {-�{.`�� ------ Material_=i��' _i i:. No. Compartments ---- ....... <br /> -�-��=�--- -- YP <br /> Distance to nearest: Well -------1 l- -------------------Foundation --------- Prop. Line ---- <br /> __.__,.____._-_-_ <br /> LEACHING LINE No, of Lines ------- ____________ Length of each line----,_-,_ ;,l------------- Total Length __a_ ___ T <br /> 'D'. Box f=: Type Filter Material-,�,f�}____-___-Depth Filter Material ------ <br /> ------------------­-----------------• -----•- <br /> Distance to nearest:,Well ----- ~__.__°_---------.foundation <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ------------------------ --- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size --------------------------..---- <br /> Distance to nearest: Well -------.---------------------------------Foundation -------------------- Prop. Line ----------_---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------_-------------------------.--------- Date _--_--__---__--_---.--__-_____.__) k <br /> Septic Tank (Specify Requirements) ----------------------------_-------------------------_ A <br /> Disposal Field (Specify Requirements) ----------------------------------------------------- ----------------------------------------------------------------- - - - --- <br /> ___••---------------------------------- ---- <br /> �- <br /> (Draw existing and required addition on reverse side) y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin l <br /> 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 become subject to Workman's Compensation laws of California." <br /> SignedSk _ Owner <br /> _ -- -- -------- - ---- <br /> BYf - - ��Z ------------------------ Title -------- - ------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMEN USE O Y <br /> APPLICATION ACCEPTED BY ----------------------- ;. DATE <br /> BUILDING PERMIT ISSUED ------ --------------- ------------ ----------------- ------ --- ------------------- ---DATE ---------------- <br /> ADDITIONAL COMMENTS <br /> -----------------------------=-------- <br /> ----------------------------------- ------------ ---------------------------------------------------------------------------------- - -- <br /> -------------------------------------------------------------------------------------------------------------------- <br /> Y: ------------------------------------------ --------------------------------------- <br /> Date ------------ <br /> f� <br /> Final Inspection b ------ - -- C -- - <br /> SAN JOAQUIN LOCAL HEALTH ISTRICT , f <br /> E_H. 9` 1-'68 Rev, SM ; <br />