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' FOR OFFICE USE: <br /> APPLICATION FOR SANIMA4I0N PERMIT i <br /> ------------------------------------ ------ `1 ,plitate?" Permit No. � <br /> i = ------------- {Complete in Tni <br /> ---- This Permit Expires ! Year From Date Issued Date 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 /> y �/ s L ' <br /> JOB ADDRESS/LOC N _ <br /> - _- _ w -� CENSUS TRACT <br /> ---------------Phone <br /> Owner's Name - -- ----------- - - ---- ---- - � ---------------- - ----�`-- - ------------------ ---------------- ...... <br /> -- - - - ----- <br /> Address -------------- s - - - ti City <br /> Contractor's Name --- - ------ � ''�--.License Phone <br /> .---------- <br /> 't <br /> Installation will serve: Residence eApartrnent House] Commercial 0Trail4 Court i❑ <br /> Motel ❑Other-------------------------------------------- <br /> Number <br /> ------- --------------------- --Number of living units:----------------- Number of bedrooms __ Garbage Grinder -------- --- Lot Size __-_-- <br /> Water Supply: Public System and name ---------------------- ----------------------------------------------- ---------------------------------Private [ ' <br /> a <br /> Character of soil to a depth of 3 feet: Sand❑ SHt❑ Clay ❑ Peat❑ " Sandy loam ❑ Clay Loam: <br /> Hardpan Adobe ❑ Fill Material ------------- if yes,type ----------------------- --- <br /> f , <br /> (Plot.,plan, showing size of lot, location of system in relation to ells buildingl,_etc. must be placed on reverse side.) <br /> It, <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if publii+ <br /> c sewer is available within 200 feet,l l <br /> PACKAGE TREATMENT [ 7 SEPTIC TANK aSize_ ! � _ t_X _--�_-_______-_- Liquid Depth ----_' .......... ..... V <br /> Capacity _1_'gb_-Cz-_' --_ Type o ------- Material--- - No. Compartments -. -c .:.....:.... <br /> Distance to Weare t: Well ---------lfb---------------------Foundation ..../Q------------.Prop. Line ------ ........ <br /> LEACHING <br /> _. <br /> LEACHING LINE [e No. of Lines ___----A_-__-------- Length of�,each line------ b_f)_`- --`- Total Length ,_. d _.�.......__ `) <br /> 'D' Box ___ ____--__ Type Filter Material •____> - -_,Depth Filter Material _-1_q-_-_- <br /> Distance to nearest: Well -----�Q-�---------- Foundation ___-_10-, -- ---_- Property Line _--_ - ' . <br /> SEEPAGE PIT [ Depth --- 5-_�-- - Diameter ---�3 -__-- Number -------o ----------------- Rock Filled Yes No .i❑ <br /> i Water Table Depth ----------Fiv I <br /> -------_---------Rock Size ------ <br /> DistaDistance <br /> nce to nearest: Well -----------1-b-�1--------------------Foundation ----�--s"J_-___..-_- Prop. Line --:-�-............ <br /> # REPAIR/ADDITION(Prev. Sanitation Permit�# -___--_: ° Date ............................------ <br /> } <br /> ----------------------------- <br /> f Septic Tank (Specify Requirements) ------------------------------ -------: -------------------------------------------------------------- ----------` ----- <br /> Disposal Field (Specify Requirements) __--------__- <br /> , 1 <br /> -------------------------------------------------------------------------------------------------------=----------------------------------------------------------------------------------------•--.-•--- <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. Hone ownw or licen- <br /> sed agents signature certifies the following: <br /> "I certify shot in the pe:iormance of the work for which 1kls permit is issued, 1 shall snot employ any person 4n wch inaetnar <br /> as to become subjecZ�, <br /> kman's Compensation laws of California." <br /> Signed---_---- =-------- a <br /> - -- Owner_ �,,.. <br /> i __ "` -- <br /> By ------------ - -------------(If othe <br /> r than owner( <br /> R .DEPARTM!<NT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------------- ----- DATE - -`c '7b------------------- <br /> r BUILDING PERMIT ISSUED ------------------------------ --HATE ------------------------------------------- <br /> ADDITIONAL <br /> ------------.-------- - -- -ADDITIONAL COMMENTS ------------------------------------ ------------------------------------------ ---------------------------------------------------=-------------------.------- <br /> i <br /> ---- ------------------------------- ---------------------- <br /> --------------------------------------------------------------------------------------------- <br /> -------------- --------- <br /> ------------------------------------ ---------------- ------ --------- - - --- --- - - - - - -- <br /> Final Inspection by: --------------------=------------------------------------------Date . ---------------------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> E. H. 9 1-'68 Rev.. 5M. 1 <br />