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' f <br /> FOR OFFICE USE: Y <br /> APPLICATION FOR SANITA ION PERMIT <br /> ---------------------------------/_0_-- -- <br /> (Complete in Triplicate) Permit No <br /> ------ ---------------------------- This Permit Expires i Year From Date Issued bate Issued _. `_ 7--- <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. 549 and existing Rules and Regulations: ' <br /> JOB ADDRESS/LOCATION -9, l �I�i /- ------------------------------- ---- --_-----CENSUS TRACT -------------------------- I <br /> Owner's Name _ l ./tfl------ -_ - -_- <br /> -�-ss-�'��----------------------------------------------------------� --- ------ .._Phone -�-��� - <br /> Address1,��_ .------- ------102'_1-------------------------------- City ......5 ------------------------------------ <br /> Contractor's Name -- J , ---- -------- - ------------------------------License #/7.;�gS7_3--- Phone --- <br /> Installation will serve: Residence_,?,,Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other --------------------------------- <br /> Number of living units:---`------- Number of bedrooms __,_____Garbage Grinder,%V__t?__ Lot Size _ d- _ _____________________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑, Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam El <br /> Hardpan ❑ Adobejkal Fill Material ------ ----- If yes, type _________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,'-'etc. must be pldced on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth __._-----------._-___-__-. <br /> Capacity ---------- -------- Type -------------------- Material---------------------- No. Compartments ---------------------- V <br /> Distance to nearest: Well ------------------------------------Foundation ------------------ --- Prop. Line ------------_-._-_•_-- . <br /> LEACHING LINE [ ] No. of Lines ___________________ ____ Length of each line-----.-------._-____--___ __ Total Length ----------------------------- <br /> 'D' <br /> ____-________-----_-___--'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ------------------- _---------Distance to nearest: Well _______________________ Foundation Property Line _______-________-_-_-__ <br /> SEEPAGE PIT Depth _______-______-- Diameter ---------------- Number --__--________________- -- Rock Filled Yes Noi❑ <br /> ' <br /> Wafter Table Depth ------------------------------------- ----------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --- ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------I <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------•----=------------------------- ---------------------------- <br /> Disposal Field (Specify Requirements) Al1VIC-1J ______ ._ _ <br /> ----------------------------------------------------------------------------------- <br /> -------------=------------------------------------------------------------=- <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) { r i <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compe sation laws of California." <br /> Signed --- --- -------------------------- --- - - ---- --------------------------------- Owner <br /> BY '-- ---- - `------------------------------- Title <br /> (If oth t n owne <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- -�aQ �` ---� <br /> ---------- ---- - ---------. DATE ------------�-----7-2_------'-- <br /> BUILDINGPERMIT ISSUED ----------------------- ---------------------------- ---=-------------------------------------DATE ---------------------------------- <br /> ADDITIONAL COMMS TSS- �_ __ <br /> 0 - - - ............................ ---- ------ -------- <br /> ------------------------------------- --- - --- - ------------------------------------------------------------------------------------- ------------------------------------- - ----- <br /> Final Inspection by: ---------------------------------Date ---- f =- <br /> / AN JOAQUIN—LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M t <br />