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•'i <br /> f <br /> FOR OFFICE USE: <br /> APPLICATION 1=01 SANl3ATION-;PERMIT - <br /> -- -- - --------------- <br /> 4-- Permit No.y]_Z <br /> (Complete in Triplicate) <br /> -------------------------------- This Permit Expires 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 appliation is made in compliance with County Ordinance No. 549 and existing Rule!and Regulations: <br /> -q. <br /> JOB ADDRESS/LO ATION --- -- ----- '.11 --------------------------------------CENSUS TRACT --------------- ---------- <br /> ---- <br /> - - - $ , f1----------- <br /> Owner's Name Phone <br /> Address ?� C�-�c�:►�Q.aY.a------- ---------------------T--------------------------- City .... --- ------------------------------------------------------------ <br /> Contractor's Name --- --------------------------------------------------------------- ----- License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence kApartment House❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑ Other -- --------- ------------------------------- <br /> Number of living units:---- Number of bedrooms-3x-------Garbage Grinder ------------ Lot Size _�_ �___X_____ <br /> Water Supply: Public System and name ------------------ ------ ------------------------------------------------------------------------------------Private` <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ,[] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ <br /> (Phot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic`tank or seepage pit permitted Lf public sewer is available within 200 feet,] W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth --------------------------- W <br /> Capacity Typ Material Q ____ No. Compartments __9�:_______-__..._ <br /> P <br /> Distance to ne rest: Well ----'-�Ur____----------------------Foundation ___ ------------- Prop, Line ... ______________ <br /> / 'XI-0F f <br /> [ ] No. o�f-Erne ------------------- -- <br /> s -- Length �-tirre.--(�3-_--- -------- Total Length --_6 ----------------- <br /> VA� 'D' Box ----- Type Filter Material b�_ Depth Filter Material ___ --------------- <br /> Distance to nearest: Well -----.!© -----_-----Foundation ._- ___.--__ ----- Property Line _ __.__.__-__-_--__ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number -------- ------------------ - Rock Filled Yes ❑ No 10 <br /> Water Table Depth ---------------------------------<-•- ------..Rock Size ------------------------- <br /> Distance to nearest: Well .----------------------'--------------Foundation --------------------- Prop. Line -----..----.---._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# -------------------------------------------- Date___,_____________________________- <br /> Septic Tank (Specify Requirements) ---------------------------------------= ---------------------------------------------------•.•--------------------------- <br /> Disposal Field (Specify Requirements) ----------------------------- y------------------------------------------------------------------------------------ --------------- <br /> ------------------------------------------------------------------------------------------------- " ------------------------------------------------------ -------------------------------------------- <br /> (Draw existing and regbired 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 shat 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 <br /> T' <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------- ---------------------------- DATE __A_V -_�ti ----------------- <br /> BUILDING PERMIT ISSUED - __ --------- ----DATE --------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------- ------------------------------------------- -----------------------------------------=--------------------------- <br /> ---------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- ----------- ------------------------ ---- --------------------------------------------------------------------------- <br /> Final Inspection by- - <br /> :--------------------------------------.Date ...... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />