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FOR OFFICE USE: APPLICATION *OW"SANITATION PERMIT <br /> Permit No ----- 3/ 9.7 <br /> (Complete in Triplicate) <br /> ---- ------------------------------ <br /> ----------- -----------"----- This Permit Expires ires 1 Year From Date Issued 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 /> described. This application is made in compliance with Cou ty Ordinance No. 549 and a isting Rules and Regulations: <br /> �j <br /> JOB ADDRESSAOCATION -L L✓J/� r -------- -5 -------CENSUS TRACT -------------------------- <br /> Owner's Name :-Ze A - --- L `--,all��f��------------------/-------------------•--------------- -. hone <br /> Address --- 7 \Syst <br /> $ '------------------------- ------- City / C ------------------------- ------ <br /> Contractor's Nam ----•------------------------------- -------------------------------License # -------------- ---------- Phone ------------------------------ <br /> Installation will sResidence ❑ Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other ------------------------------------------ <br /> Number of living --- Number of bedrooms _-__ _Garbage Grinder ------------ Lot Size --_�fo- -I-��- <br /> Water Supply: Puand name --------------------------------------------------------------------------------------------------------------Private ❑Character of soil t 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Q' Fill Material ---------)- if yes,type ------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, b i ings, etc. must be placed on reverse side.) \ <br /> NEW INSTALLATION: (No septi tank or seepage pit permitted if pu ewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTI TANK f ] Size------------- ----------------------=----------- Liquid Depth --------------------- ----- <br /> Capacity ------ ------------ Type --------------------- erial---------------------- No. Compartments --------------... �U <br /> Distance to n rest: Well "-_ _� ---- --------------Foundation ---------------------- Prop. Line --_.---_---_--_------- <br /> LEACHING LINE [ ] No, of Lines en`gth f ea i - -- Total Length .------------------_-------- <br /> --- - -- -- - -- <br /> � ' -Depth Filter Material _-_-.-------_ <br /> 'D' Box ----- ------ T e Filter atena ^ <br /> Distance to nearest: Well ------ --------- Foundation . ___"""""-___ Property Line """"""_._.___""_......." <br /> SEEPAGE PIT [ ] Depth ---------- iameter ----- ---------- Number -------------------------- Rock Filled Yes ❑ No C—jj <br /> Water Table Depth ---- - -------=---------------------------------Rock Size -------------------------------- _. <br /> Distance to nearest: Well --------------------------------------Foundation -------------------- Prop. Line _..-----"_..-..------. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ---------- __-------------------------- Date -------------- <br /> ----------------------------------- <br /> Septic <br /> ----_--_-._-""_"_ f-- ---__"_J <br /> y Se tic Tank (Specify Requirements)t Ca-C6j--- -'---�-�-------A $- -----t- ,J-------- ... <br /> P ( P Y q 1 , ------------- <br /> DisposalField (Specify Requirements) ----- -------------- --------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- --- -----------------------------------=-------------------------- <br /> t <br /> r <br /> --------------------------------- ---------------------------------------------------------------------------------------------------------- <br /> (Draw existing and req ired addition on reverse side) <br /> 1 hereby certify that 1 have prepared this application cincl at the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations 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 pe it is issued, I shall not employ any person in such manner <br /> as to becom subje t to Workm n's a aeon laws of Calif rnia." <br /> Signed ---- -Cl,__- -- <br /> ------------------- Owner <br /> IBy --------------------------------- ------------------------------------------------------------------- Title ----------- ------------------------ ------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B ------------ --------------------------------- DATE ---- <br /> BUILDING PERMIT ISSUED ----------- --------------------------------- --------------' ------------------------- =--------------DATE -------------•------------- <br /> ADDITIONAL COMMENTS --- -------------------- ---------- ----------- - ----------------- -- <br /> ----------- --- ----------- ------ <br /> f -- --------------- <br /> ------------ -----------------------(-:,: --- - ------ ----- - -- - - ---------------------------- <br /> -------------------- ----------------------- ------ ----- - <br /> ---- ---------------- <br /> FinalInspection by: ---------------------- ---------------------- -- - ---------------- a <br /> SAN JOAQUIN LOCAL HEALTH DIST ICT i <br /> E. H. 9 1-'68 Rev. 5M <br />