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'- FOR OFFICE USE: APPLICATION FOR 5�►NITATI4N PERMIT 1 <br /> ------------------------------- ------------ Permit No: - --�-�--�-��--7-' <br /> (Complete in Triplicate) <br /> - --------------_----------------------________-___.--- This Permit Expires ] Year From Date Issued Date Issued <br /> F <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/LOCA,TTIION . y�--------,-�XV�----- CENSUS TRACT �r <br /> Owner's Name .-/�/1f -------,�PJr � tl t� -----/ � t l------------------------- ------Phone f�i �5_�_a'fa-s ------- <br /> Address .../.(� ----- ---------- • _----------. City � y am- <br /> Contractor's Name - f' --- ----- -------.License # ------ Phone Adr-- f_-_ <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ❑ <br /> Mote/el ❑Other -------------------------------------------- <br /> Number of living units:----J--- -. Number of bedrooms __2„__ rbage Grinder ------------ Lot Size _________________________________________ <br /> r <br /> Water Supply: Public System and name _-_ -_ " - -� - <br /> - � ------ ---------------------Private ❑ <br /> e <br /> Character of soil to a depth of-3 feet:.--....Sand'[]...-Silt-❑..._:..Clay..❑ Peat E] Sandy Loam El /Clay Loam El <br /> r Hardpan E] Adobe" Fill Material _ `___ If yes, type _________ _______________ <br /> (Plotiplan, showing size of lot, location of system in relation to wells, buildings, etc. _must be placed<on reverse side.) <br /> NEWIINSTALLATION- (No.septic tank or seepage pit permitted if public sewer is availdble within 200 feet,) <br /> PACKAGE TREATMENT [ ] ISEPTIC TANK [ ] Size--I __ _ --�------ __--_ Liquid Depth __ _. _ _ __ <br /> Cap city -------------------- Type -------- -Material-------- _ :, No. Compartments <br /> fDistance to,nearest: Well _______________Foundation ---------------------- Prop. Line ----------------- ------ <br /> f <br /> LEACHING LINE ( I No. of Lines ------------------------ Length of oath line---------------------------- Total Length .__-__-.____._____-_-----_-__ <br /> i 'D' Box ------------ Type Filter Material _____?______________Depth Filter Material --------- <br /> € Distance to nearest: Well _____ _______________-I Foundation __._ __-.-____ Property Line ------..__--.--_.__:._.. <br /> CSEEPAGE PIT [ ] Depth -------------------- Diameter ---------------I Number ----------------------------- Rock Filled Yes ❑ No i❑ <br /> a a Water Table Depth ----------Rock Size ____._ <br /> I Distace to nearest: Well ____________ _ ________________-___Foundation-,______.___________-- Prop. Line....................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------I----------- Date ---------------------------------- 1 <br /> 'Septic Tank (Specify Requirements)-<=:-_.�--�-�. ==—--- - = ------------------------------------------------------------------- ----- ------------------- <br /> I `7 <br /> F 10_ r - <br /> Disp al Field {Specify Requirements] -___�� c ----- -- ---le -=---- - ------------ <br /> �.,�. <br /> ----�.: -- 4(/) - - ------ <br /> ------------------------------- ------------------------------------------------=----------------------------------------------------------------------- -=----------------- <br /> i - - - -- - --•- (Draw existing and required addition on reverse side) <br /> I herFby certify that IRhave 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 Distr#ct. home owner or licen- <br /> sed agents signature certifies the following: <br /> f "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 Compensation laws of California." <br /> k <br /> Signe ------------------- ---------------- --------- -------------------------------------------- Owner <br /> By Title 6 r------------------------ <br /> - ----- --------------------- <br /> r (If other than owner) <br /> t <br /> € AR7MENT USE ONLY �7 <br /> APPLICATION ACCEPTED BY . ----- ------------------------------------------------------- DATE -----�j'-=/l '--`— /- - <br /> t BUILDING PERMIT ISSUED ------ --- -- --- -------------DATE ---�-------------------.-------------- <br /> E ADDITIONAL COMMENTS <br /> -7r- -P-? --------------- - - --------- -- <br /> --------------------------------------- --- hil � �r'� / <br /> --------- �" r'� <br /> ---- ------------------------ <br /> Final Inspection b --- --- - -V----- -------- ------Date ---- -1J f <br /> l <br /> NWt"�U.I'N VLOCAL HEALTH DISTRICT <br /> t E. H. ,9 1-'68 Rev. <br />