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r i i <br /> It APPLICATION USE: APPLICATION FOR SANITATION PERMIT -7 -76 7 <br /> ----------------------------- (Complete in Triplicate) Permit No. . . -------------- <br /> -``'------------------------ --------------- a <br /> This Permit Expires 1 Year4rom Date Issued Date Issued __- <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work. herein <br /> described. This application is made in compliance with County inane` N 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- - - <br /> -------- ;_c -------- -- ---- ------------- CENSUS TRACT ---------='---------•------ <br /> Owner's Name ---------------- <br /> - -------------- <br /> ----- ------Phone <br /> Q <br /> Address --------3 E} ----- -- - - --=- --- 4.------------------------•--. City. - <br /> Contractor's Name -.--- -- - -o-- <br /> ------------License # -.I_ - one k, <br /> Installation will serve: Residence artment House❑ Commercial :[]Trailer Court ;❑ <br /> ' Motel ❑Other -------------------------------------------- // <br /> Number of living units--------- <br /> Number o --------------------------------------------- <br /> rooms, -_--- -__-_Garb ge G 'nder _ Lot Size or//---- /---- --------------- <br /> Y ----- �-� -.. Privat <br /> ' Water Supply: Public System and name ------_- e ❑ <br /> k Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ a <br /> Hardpan ❑ Adobe- ill 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.) v <br /> i <br /> NEW'INSTALLATION: (No septic tank'or see age pit permitted if public sewer is available within 200 feet,) 01111 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 'ze-_ �� -_---__-.-- Liquid Depth -- ---�/-,: ------.••. <br /> y _ Material-- " ------- ------ Compartments --- ----------- <br /> Capacity --/ -- - ----- Type ��----- <br /> d Pro Line --- rel <br /> D' tante to ned st: Well -------��---------------Foundation _ _.__- p. -----J--------- <br /> LEACHING LINE [ No. of Lines ---- - -------------- Length of ach line---- �­�---- Total Length , _-....---•---- <br /> �.. !/ <br /> 'D' Box - �` Type eller Material--- _ Foundation Depth t� MateriaPropertyfl Line. 1 <br /> Distanced_neare t. W �/ <br /> I <br /> SEEPAGE PIT [ epth ___c -s--�-- Diameter �-------_ Number -.--- .�-. ---- Rock Filled Yeses.❑ <br /> r �• <br /> Water Table Depth --------fP-0------------------------------Rock Size ----- <br /> Distance to nearest: Well ------------ �---------------Foundation --:�- ---------- Prop. Lirie --_/.....- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_------___-----=:-------.------} <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------- -----•----- ------` ---------------- <br /> Disposal Field (Specify Requirements) -------------------------------------------------------------------------------- _ ------------------------- --------:-- <br /> M �. <br /> -------------------------------------------------------- ------------------------------------------------------- ----------------------------------- ----------------------------- --------------- <br /> --------------------------- --- <br /> __ _ _ _ _ _ _ _ _____ ______________ ' ------_-------------_--•---_-------_--•-•-- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby,certifyprepared <br /> that I have this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Mules and Regulations of the San Joaquin Local Health-District. Home owner or licen- <br /> sed agents signature certifies the following: r <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 h <br /> BY ----------------------- {. ---l-.v�.- -------- <br /> --- Title - ----------- <br /> - I �' <br /> (If other t an o ner} f �- <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- ---------------------------------------------- DATE Z3 7� ----------------- <br /> BUILDING PERMIT ISSUED '- ` --------------------- __ M ---------.—DATE•- --- _'= ----------------- <br /> I <br /> ADDITIONAL COMMENTS - f 3----- '� ,t / ----------------- <br /> - ------------ <br /> -------------------------------------------------- l �� - ----a ,�- --- -------------------------------- <br /> ----------------- <br /> --------=------------------------------- -- ----- --- <br /> -- --- ----� r-"--- .µ--- ------ --------- - ------ - - - <br /> / t -----------------------Date -------------------- ------- <br /> Final Inspection by: -------- ---- <br /> SAN JOAQ IN LOCAL HEALTH DISTRICT m <br /> E. H. 9 1-'b8 Rev. 5M - _. <br />