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k <br /> y . -"FOR OFFICE USE: "0 ., <br /> APPt1CATlOI� F6R 5ANITAT[ON PERMIT �, <br /> r, <br /> ------ -------------------------------- ---------- ----- ' Permit <br /> (Complete in Triplicate) Date Iss <br /> a --------- ued5 <br /> -------=----------------------------- <br /> - - ---------- <br /> This Permit Expires 1 Year From Date Issued <br /> --------- ------------------------ - ------ <br /> Application is hereby made to the San Joaquin Local Health bistrict for a permit to construct and install t work herein <br /> described. This application is made in compliance with County Or ance No. 549 and existing Rules andRegulations: <br /> t JOB ADDRESS/LOC = a"�0 <br /> ------------ ----------CENSUS TRACT -------------------------- <br /> U <br /> Owner's Name _V--------------------- --------- <br /> _-! <br /> --------------Phone . 7 ' � <br /> -- ---------- -----------�--J-- --- <br /> `L :. -- <br /> 41: <br /> T' city - <br /> Address --------- --------------------- I-- � - � /� <br /> [ Contractor's Name ------ <br /> ---------- Got - �"`----------- License # _l-cry S�� Phone .: G-�T-_¢ <br /> Installation will serve: Residence$•Apartment House'(] Commercial:❑Trailer Court_,Q <br /> tMotel ❑Other -------------------------------------------- <br /> g Grinder ------------ Lot Size -_f/Z X-------��------ <br /> Number of livor units:__.___ -_-- Number of bedrooms ___ _ __Garbage _ private ❑ <br /> Water-Supply: Public System and name ------------------------------------ <br /> ------ ------- --------•----__ <br /> ` Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ <br /> Hardpan ❑ Adobe X Fill Material ------------ If yes,type ---------------------------- <br /> 4 <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: - INa Septic tank or seepage pit permitted if public sewer.is available within 200;feet,}� `� <br /> oe � � <br /> SEPTIC TANK',{ , ;Size------ X�'----- ------------ Liquid Depth r� -----------_ 0 <br /> f PACKAGE TREATMENT ._.:- t]`� :. <y <br /> ( CapacityMaterial_. '_J. <br /> f------ No. Compartments ---------------------- <br /> t s <br /> %; Distance to nearest Wel! our�d <br /> Fation4___f--D <br /> ------------- Prop. L �- <br /> Line _ <br /> _---i -- Total Lengthy ', �7 Q <br /> LEACHING LINE r No. of Lines --------y-------- Length of each `line._ ' - "- <br /> ! 'D' Box ____ Type.Filter'-Material -----Depth `Filter :Materia{ -.� ---------- ---------- <br /> �+ <br /> y ion f -------------- Property Line Q <br /> I Distance to nearest: Well _______-__._�__-__.___ Foundation <br /> I_______ Diameter 3.r '71_-------- Rock Filled Yes No 0 9' <br /> . SEEPAGE PIT Depth �-� --- ------------ Number --------------- .. <br /> `� wR r ziz <br /> TM Rock Size I-- ------- <br /> 4 =`.,`G+/ater"-Table Depth...------------ ------- --- ------------=------._ -, --------•---- i <br /> . Foundation � __f--------- Prop. Line _S- ------------ <br /> Distance <br /> to nearest: Well _.__-__.___-- -------------- - <br /> E <br /> REPAIR/ADDITION(Prev. Sanita n Permit r# -------------------------------------------- Date ----------------------------------} <br /> i Septic Tank (Specify R �uirts). --------------------- - " - <br /> Disposal Field (SpecifyRequirements) <br /> ---------- ---------------------- <br /> y ------------------------------------- <br /> r.. ------------------------------ --------------------- --------------- -------------------- <br /> _ <br /> (Draw existing and required addition on reverse side) <br /> r hereb certify that'I have prepared thi application and that the work will be done in accordance•with San Joaquinti;= <br /> y fY <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 he-follawing: <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 /> s - ! California." <br /> Signed ----------------- ---------------------- Owner <br /> ---------------------- ------ <br /> A. <br /> Tite --------- -By ----- ----------- ---- <br /> (If other than -s-~- <br /> FOR DEPA1tTMENT USE ,ONLY <br /> f—�� / <br /> APPLICATION ACCEPTED BY `- - r`` ' �'. ----------------- DATE - �7 <br /> ------'_--- = ----- <br /> BUILDING PERMIT ISSUED --- : ---- ---------------- ATE -------------- <br /> ----------------------------- <br /> v� a.. -u- - �j------ - - - ----- - <br /> ADDITIONAL COMMENTS _-__ c- ---------------------------- <br /> n �� <br /> ----------------- <br /> - --------- <br /> 7s 0�------- ' <br /> - <br /> -------------� <br /> - <br /> ----------------------------- <br /> ---------------- ------------------ <br /> --------�-- ----- ----- ---- ------.Date __�:� -------'-- ------- ----- <br /> Final Inspection by.. ------- <br /> SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. SM <br />