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FOR OFFICE USE: <br /> A <br /> ,.,APPLICATION FMSAFTION PERMIT I <br /> 4� 1� <br /> V (Complete inTriplicate) <br /> Permit N o <br /> Date Issued -Iq <br /> This Permit Expires 1 Year From Date Issued <br />----------------------------------------- --------------- <br /> A <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 /> -3 -------- <br /> JOB ADDRESS/LOCATION ------ - --------------------- --- -------------CENSUS TRACT -------------- <br /> Owner's Name -------Phone <br /> -------------------------------------------- ------------ <br /> -- - - ------------------ <br /> Address --------------------------------- ."I-, 2__ <br /> -------------------------------------- <br /> 791_� ------------ ------------ city <br /> --------License Contractor's Name se # -------4_K SY!7e�_ Phone li��-----------------__ <br /> Residence S. <br /> Installation will serve- Apartment House,U Commercial �.E]Trailer-Court- <br /> 4" Motel E] Other -----------------I-------------------- <br /> arbage Grind Lo ------ <br /> Number of living units:-.- Number of bedrooms --C;Z-G Grinder ------------- t Size ---------- <br /> Water Supply: Public System and name ------------------------------------------------------------- ------------ ------- Private <br /> 'je <br /> Character of soil to a depth of1feet: Sand F] Silt E] Clay, E] Peat E] Sandy Loam -E] Clay,Loa <br /> Hardpan Ej Adobe-[-] F I ill Material ------------ If yes, type ------------------ <br /> ---------- <br /> (Plot plan, showing size .of lot, location of system in relation torwells, buildings, etc:'-must be placed on reverse side.) <br /> NEW INSTALLATION: /(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT, SEPTIC TANK, I Size-------------------------------_--.-_----- ---_ Liquid Depth -----------_------------- <br /> rapacity ------ ------ ------ Type ------------------Material------------------- No. Compartments ...................... 11% <br /> I W <br /> Distande',to. neare'st. Well _--_--_---------------------c_-_---Foundation ------------------'Prop.-tirte—------­­------- <br /> U <br /> LEACHING LINE [,r] p Na ofjines ------ Length of each'line---------------------I­------ Total Length ------------ ---------------- <br /> V Box------------ Type Filter Material ----------- <br /> --I------ <br /> Depth FilterMaterial -----------------------------­­­-------- <br /> Distance to nearest: Well ------------------------- Foundation ----------------- ------- Property Line -------__------------ <br /> ---------- Rock Filled Yes No C] <br /> SEEPAGE PIT [7e Depth I ------ Diameter ------- Number --------------- <br /> --- <br /> Water fTable]Depth ----------------------------------------._.....Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------------------- Foundation -------------------. Prop. Line ------------_ ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ------- -------------------------------- Date .--_-_--.-__-.--_-_ <br /> Septic Tank (Specify Requirements) --------------- ----------- <br /> -----------------------�4------------- --------------- <br /> kl <br /> .....er, -------- ----- ------------------------- <br /> Dispo -------------- - --------- <br /> sal Field (Specify Requirements) ----0 <br /> ty <br /> --------------- <br /> ------------------ ----------- &P-i ------------------------------------------ <br /> -- ---------- <br /> ---—------- <br /> zA <br /> ---------------------------------------------- ----- <br /> - <br /> ' -i -si-4 <br /> _ 'f(Drciw existing and required addition on reverse side} <br /> application and that the work will be done in accordance with San Joaquin <br /> I hereby certify that I have prepare-clTihis, <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 /> /' I <br /> as to be �-me subject to Work an s Compensate n laws of California." <br /> -------- -------�) - ------ Owner <br /> Signed t_jA1-_X, -_?_ J_ <br /> JAJ-1 Title ------------------------------------------------------------------------ <br /> By ---------------------------------------------------- <br /> (if other than owner) <br /> FAR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- ------------------------- ------------- DATE -------- <br /> BUILDING PERMIT ISSUED -------------------------------------- - ----------------------------------------------------------------DATE ------------- --------- ---------_-------- <br /> ADDITIONALCOMMENTS ------- ------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - <br /> -------------------------I- ------- - ---------------------------------- ---: -�V--------------------•----------------------------------------- <br /> 3e) ---------------- <br /> ------------------------------------------------------- <br /> ---------------------------------------------- ---------- <br /> ?/"_� --------- --- --------I - <br /> ------------------------------------ <br /> ---------------------------------------Date <br /> ---------------- <br /> Final Inspection by: --- -------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9, 1-'68 Rev. 5M <br />