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FOR OFFICE USE: .� <br /> "'APP-LICATION FORta;,SANIIATION IPERMIT -33 <br /> ,. _. <br /> - 1 'ermitfiio. -- 7--" <br /> �— $Complete in Triplicate} <br /> = ° ---------- --------- !% ->3 �3 <br /> r� Date Issued __l_.______ -_-- <br /> This Permit Expires 1 Year From Date Issued <br /> ------------------------------------------------ <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 <br />` -�r--`�: <br /> �� ---CENSUS TRACT ------ ----------•-------- <br /> . --�®��/--- ./'„�•--�-- <br /> �_'� ---- ---- --------- <br /> Owner's Name /' ( y ------ -------------------Phone -------------------------- --------- <br /> -------------�-_t V - -- � <br /> Address --------- -------------/-----------rs -rye -r ---------------- City --- ----------- <br /> f-V <br /> Contractor's Name ----A- � �' -------- <br /> ----------------License # .._ � , .1_ Phone _ SZ. .� <br /> Installation will serve: Residence partment House❑ Commercial :❑Trailer Court ':❑ <br /> Motel Other ---- ----------------------- t <br /> ❑ A <br /> Number of living units:_-.- ( ___ Number of bedro s _ --------(arbage Grinde /l�A___ Lot Size --------------------- -------------------­- <br /> Water Supply: Public System and name --------- -------- n <br /> - - ------ -----------------------------------------Private ❑ <br /> 'I Clay Peat Sand Loam ❑ Clay Loam ❑ l <br /> Character of soil to a dep,h of 3 feet: Sand ❑ Sit❑ y ❑ Y <br /> Hardpan ❑ Adobe Fill Material ----iVf _'� If yes,type ____________________________ i <br /> (Plotpla,yshowing size of lot,.-location'oof system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> .1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within X100 feet,) <br /> • 3 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Y --- ----- ---- Depth'�----------------------- <br /> Capacity Type -------------------- Material---------------------- No. Compartments "=--- ..-•------_-.-- <br />- P YP) <br /> Distance to nearest: Well _.__-----.---_______________________Foundation ---------------------- Prop. Line ---._________ ----__ <br /> LEACHING LINE [ ] No. of Lines -- ----------------- Length of each line-------_------------------- Total Length ,_____--_._______--------. <br /> t r <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.----------------••----- i <br /> Distance to nearest: Well E__________________-___ Foundation ------------------------ Property Line ------------ -_---- <br /> { <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------,---.--.--------------- ❑Rock Filled Yes No <br /> C] <br /> r Water Table Depth ----------I------------------------ Rock Size ---------------------------=---- <br /> ' Distance to nearest: Well ----------=------------ -- ------:----.Prop. Line --------------.___-_-. .' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_------------------------------------ Date ------------------7--------------- , <br /> Septic Tank (Specify Requirements) ---------------------------- <br /> Disposal Field [Specify Require!ts) ________-L _ . u'_T___-- ------ � -_---- " _------- <br /> S ,, f <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 peHormance of the work for which this permit is issued-, l shall hot-employ any,person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> [ � wA <br /> 1 -4- <br /> Signed - -- ----- ------- _ -------------- O ner <br /> B T e -------- ------- - -------- <br /> _ R <br /> o ekr than owner) <br /> `^ w� ,N , OR TMENT USE ONLY_' <br /> 4 APPLICATION ACCEPTED BY -- -° DATE -.-L-:-- --7 ------------------ <br /> ----- <br /> BUiLDING PERMIT ISSUED -----`---- --- ._ -T rR -------------------- -. <br /> ADDITIONAL COMMENTS ---- -- - ------ --- ----------------------------- — ._. <br /> = - ----------•----- <br /> --- ------ ------- -------------------------------- ------------------ <br /> - f ------- = <br /> ' Final Inspection by: ------------- - ---------- --------------------------------------------------------------------Date -------- <br /> AN <br /> ------ 1- y ' <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 , <br /> E. H. 9 1-'6$ Rev. M <br />