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FOR OFFICE USE: APPLICATION FOR SA14ITATION PERMIT <br />----------- -------------- <br /> ------------ - ------ - ---��--�-� <br /> (Complete in Triplicate) Permit No: T;�-- <br />--------------------------------------------------- <br /> ------ Z Z w :. <br /> Date Issued -------------------- <br /> This Permit Expires 1 Year From Date Issued <br /> l{ r <br /> l#h District for a permit to construct and instal! the work herein <br /> Application is hereby made to the San Joaquin Local Hea <br /> described. This application is made in compliance with,County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L PlTI N Y,�447_1--------e-��------- -- -- --- ---------------- -------------- <br /> --- ------CENSUS TRACT ---------------- --------- 0 <br /> Owner's Name ---- -- -------- <br /> ---�---- --------------------------------------------------- -----------Phone ------------------------------------ <br /> in <br /> ----------------------------------- <br /> (pAddress --------- 1 ---------- ---------------- City A! n 1-�-��3 --------------------------------------------- <br /> Phone ------------------------------ <br /> Contractor's Name ---- - .--- - License # <br /> installation will serve: Resident Z AApartment House❑ Commercial :❑Trailer Court •❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ Number of bedrooms.-.--,. -_.Garbage-Grinder-------.--- Lot Size - �`'`¢'�--------------- <br /> 4 ,] <br /> Water Supply: Public System and name ------------------------------------­---------------------------------------------- --------------------•..-----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 /> r <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 pit permitted if public sewer is avciilable within 200 feet,) ' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] b Size------------------------------- -- --------- Liquid Depth -------------------------• IN, <br /> Capacity ---------- --------- Type -------------------- Material------------- No. Compartments ---------•------- <br /> Distance to nearest: Well ----��---------------------------Foundation---------------------- Prop. Line ------ --------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------.----.---------------- <br /> 'D' Box ------------ Type Filter Material --- -------Depth Filter Material ------------------------------------•-.----- <br /> Distance to nearest: Well ---------_;._---------- Foundation --------- ---- -------- Property Line. ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ------ Number__' _'__-" Rock-Filledl—Yes`❑ No ]` - "" <br /> 1�1 <br /> i i <br /> WaterTable Depth ---------------------------------------=--------Rock.Size----------------'----------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -`-------- -------- Prop. Line --------..------_--- <br /> ti <br /> r . ) <br /> REPAIRJADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------•=------- --_•--- <br /> Septic Tank (Specify Requirements) ------------------ 4 <br /> y <br /> ` ..� ---- Y <br /> Disposal Field (Specify Requirements) - _.-- --- -•-• -------- <br /> ----------------------- <br /> ------------ (r <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 performance of the work for which this permit is issued, I shall not employ any person .in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------ --- -------------- Owner <br /> 2 <br /> BY Title - ------- ----k, ----------------------------------------- <br /> ------------------ ------- ----- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE --- <br /> BUILDING PERMIT ISSUED ------ --------------------- -------------- -- <br /> ---------------------------------------------=--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS __1--- ------------------------------------------------------------•------------------ ---------------------------- ---------------=-------- ------------------ <br /> ------------------------------- ---------------------- ----------- ------------------------------------------ ---- -------------- - ---------------------------------------_---------- I <br /> --------------------------- -- ---- --- ---- <br /> Final Inspection by-. -: -------------------------------------------------------------------------.Date -r-�- " a"' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />