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FOR OFFICE USE: <br /> �r3u <br /> A,^- APPLICATION PSR SANITATION PERMIT 3-�7 <br /> {Complete in Triplicate) Permit No, __7_________________ <br /> --- ---- ----------------------------------------------- `� (31 - 370-02- <br /> _-- -----_------'----------------- This Permit Expires 9 Year From Date Issued <br /> Date Issued <br /> Application Whereby made to the San Joaquin Local Health District for a permit to con truct and install th work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATO .� <br /> I/_.__P _._ Id �__fc�` __.� _y y- --.-�1V-:.0_�_ _,_CENSUS TRACT --------------____________ <br /> Owners Name Y - ------ -- Phone ------------------------------------ <br /> Address t <br /> - City ------------- <br /> ------------------------------------------------------------- <br /> Contractor's Name ----- �� -- -----------------License # ----- PhonetS - <br /> Installation will serve: Residence ❑Apartment House-E] Commercial' Trailer Court <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:_._______ Number of bedrooms ________Garbage Grinder Lot Size 1' 400 p_r-----_-______---:_ <br /> Water Supply: Public System and name ---------------------------------------------------------------I------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ - <br /> Hardpan ❑ Adobe ❑ 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 /> NEW INSTALLATION: (No septic tank or seepage it permitted if public sewer is available within 200 feet,) / <br /> PACKAGE TREATMENT ( ] SEPTIC TANKSize__ _ p--2[___-.___________ Liquid Depth .....__A <br /> Capacity/�0_____.:__ T ,1-r---$— _ Material.i_°N C_-�_______ No. Compartments __________ <br /> Ypf� P <br /> Di ce to nearest: Well ----/1�____________________Foundation <br /> r_______ Prop. Line _________ _�___ <br /> LEACHING LINE No. of Lines ---------/_________._ Length of each lin ______f. ___cz__�.______ Total Length ____Q_-_............ <br /> --- ! 'J ; <br /> // P . <br /> p' Box .___ ____ Type Filter Material�gq�__ 1 :Depth Filter Material __.____� ------------------------------ <br /> 'D' <br /> __________________________-- W <br /> Distance to nearest: Well __' _ _________ Foundation -------/ra-----______ Property Line ------- <br /> i <br /> SEEPAGE PIT [ ] Depth _.. _.__________ Diameter ________________ Number ---------------------------- Rock Filled Yes E] No ,i❑ <br /> Water..Table Depth --------------------------------------- -------Rock Size -------------------------------- <br /> Distance <br /> ------------------------------Distance to nearest: Well ________________________________________Foundation ----------------------- Prop. Line ......... .......... <br /> REPAIRJADDITION(Prevr Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Sep is Tank.(Specify-Requirements) _____ _______ _._- J-----------------------------------------------------------------------:---------------- -•--------------------------- <br /> t <br /> Dis�osal Field (Specify Requirements) ---- ------------- ----------------------------------------------------------------------------------------------------•----------- <br /> 3 <br /> ,- y-------------- ,; ---------------- -------- --- -- ---------------------------------------------------------------------------------------------- <br /> (Draw existingand re --fired <br /> q a ition an reverse side) <br /> I''hereb certif that I hove prepared this application and that`1he-work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations,ot the San Joaquin Local Health District. Home owner or [icon- p <br /> sed agents signature certifies the following: <br /> 46 <br /> 1 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 becom subject to Workm Is Compensation' laws of California." <br /> Signed ...... Owner <br /> BY ------ ------ Title -- ---- --------- ---- ---- ------------------------------------------ i <br /> (If- er than owner); <br /> tea " u� ENT USE ONLY <br /> APPLICATIO�J,ACr PIED BY ------ DATE �.{ �? <br /> BUILDINGPE .ISSUED -------------- -- ------ - ---- - ----------- ----------------------------------DATE ------------------------------------- <br /> ADDITIONALCOMMENTS -------------- --- -- -------- -- ----- -- ----------- -------------------------------------------------------------------------- ----------------------- <br /> �' <br /> ---- ---------------- <br /> ---------------- ---- --`-------- ----- --- - ----------- -`----------------------------------------------------------------- -- - ------------------ <br /> Final I spection by: -----d --- ------ ----------------------•-------------Date <br /> SA AQUIN LOCAL HEALTH DISTRICT <br /> H. 9 1-'68 Rev. 5M <br />