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FOR OFFICE USE: �� <br /> APPLICATION FOR SA IN TACTION PERMIT <br /> -------------------------- Permit No. -- --------------- <br /> (Complete in Triplicate) <br /> --------------- ----------------------------- <br /> l --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> w <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 County Ordinance No. 349 and existing Rules and Regulations: <br /> JOB AQDRESS/LOCATION ._s � -3_._ .___�T d � __ __CENSUS TRACT _________________________ <br /> -. { <br /> Owner's Name - . k ------_.. — Phone 17--------------•----•---•----; <br /> _ <br /> Address I�--J-� �'oV w --e�-g------ City <br /> Contractor's Name --- ------------/ =-:License # _ 3 ' hone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑Trailer Court ',0 <br /> Motel ❑Other _' -�'- -C�_.. ......... <br /> g n.�____Garbage Grinder - !� __ Lot Size ._5_G___ . <br /> Number of living units:--_____�._ Number of bedrooms __ ------------ <br /> Water <br /> _ ________ <br /> Water Supply: Public System and name _______________ __Private,( <br /> I Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay.Loam <br /> i Hardpan ❑ Adobe-E] Fill 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 /> k v � <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200,feet,) Y d <br /> PACKAGE{TREATMENT SEPTIC TANK Size_- f L - {'1 <br /> { l � 7 -�-�--•9 �- - - - Liquid Depth'---�---.......-.----- <br /> i i ----------- <br /> Capacity Q/ _�96..tr_ oii-p_rfm n �.__�� <br /> �T -��-� - -.-- Type -----------------� Material----__�d___ r No. `Con-ipartmenfs --_-:---- ; -------- <br /> Distance to ne est: Well ------------------------------------Fouridation ___ 'Prop. Line ____�______________ - <br /> - .� <br /> LEACHING LINE No. of Lines -----------/---------- Length of each line------ <br /> --------------=__: Total Length __ _ ----------------- <br /> r+ 'D' Box __„__._---- Type Filter Material _____�_�Z____.Depth Filter Material ____Ig ----------------------•------ <br /> __�� <br /> Distance to nearest: Well '-_- Q-- _ Foundation ------/�---------- Property Line. ------------------------ <br /> Diameter « Number _.____.._. __ <br /> SEEPAGE-PIT Depth __�._--��_ r ___��.______ - �--------------- Rock Filled Yes � No <br /> � r <br /> '�- Water Table Depth._-.- -----/jP-Q=---------•- ---•---------Rock Size _// X_ - ----------- <br /> Distance <br /> -Distance to nearest: Well ___:____` ----------------___------Foundation ----/_0---------- Prop. Line _.. .._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-_________________________) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------=- -----•---------------,----------------------------- <br /> Disposal Field (Specify Requirements) ------------------------- -------------------------------------------------------------------------------------------•--------------- <br /> � j. <br /> F ------------ -------------------•--------------------------------------------------------------------------------------------•- <br /> I <br /> -- - -------- --- - - --- - -------------------------------------------------------•- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <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 /> Signed --------- ------------------------------------------- ------ Owner <br /> BY ---------- itle ------------------------------------- <br /> (If other than owner) <br /> FOR DEPJ RTMENT USE ONLY <br /> t APPLICATION ACCEPTED BY DATE - <br /> --- ------------------ <br /> i BUILDING PERMIT ISSUED ---------------------------------------------------------- ------ -------DATE ----------------------------- ------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------------------- - ----------- <br /> ---------- -------------------------------------------------------------------- ---------I--,------------------------------------------------------------------------------------------------------- <br /> -------------------------------- ------- <br /> I Final Inspection by: -------- �� 1 ----- ------------------------------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> E. H. 9 1-'68 Rev. 5M <br />