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FOR OFFICE USE: <br /> PPl.ECAT'EOEV FOR 5ANiTAT€O[1i PST 7� <br /> Permit No. _... .__.. <br /> (Compiote in Triplicate) --- <br /> s <br /> .�"".,.......................-.........-................ This Permit Expires 1 Year From Date Issued <br /> Date Issued /.....� .-7S <br /> kl <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 /> l �- <br /> JOB ADDRESS/LOCATION .._ . - -_..- !/ '� ._-" ................. <br /> Owner's Name ......�.'ar. .._ -• . •-•---• = <br /> .................... •----••-------- <br /> ..._.....-- ... Phone <br /> Address �-c�-��- -�f�..--�-- --6. . �f ....f.�. _........ . City ....................................... <br /> _. . �° �----�-~r-°c� <br /> Contractor's Name ----- + - __.. -- - ' <br /> ----------.<_._.License # Phone .............................. <br /> Installation will serve: Residence eApartment House❑ Commercial ❑Trailer Court <br /> t Motel ❑Other ...........................••-------------- <br /> Number of living units;.-......�... Number of bedrooms __....Garbage Grinder ___._...__- Lot Size ............................................ <br /> Water Supply: Public System and name ----•------•-••---------- --------- ------- --••-•------------ .........._Private ❑ <br /> r <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Tr 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 pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.................... ........................... Liquid Depth .......................... <br /> �1 <br /> Capacity ..---------•---•---• Type ---------•---------- Material--------------- -----• ;No. Compartments ..........:..:............f <br /> Distance to nearest: Well ----- ------Foundation ..................I... Prop. Line ...._... ............. <br /> LEACHING LINE [ ) No. of Lines -------------- ......... Length of each line --------------------------: Total Length --------....................In <br /> �J 'D' Box --.._ ...... Type Filter Material ....................Depth Filter Material .......................................:-----. <br /> k. Distance to nearest: Well ........................ Foundation ......................:. Property Line .........................C:: <br /> SEEPAGE PIT [ l Depth --------------- ._.. Diameter ...... Number __------------------------ Rock Filled Yes ❑ No <br /> Water Table Depth ...........-.....................___........Rock Size ................................ <br /> Distance to nearest: Well.........................._----_.._.--Foundation ............... Prop. Line.........---.__..-_. - <br /> REPAIR/ADDITION(Prey. Sanitation'Permit --•--------................................. Date ................. ................ <br /> lr. <br /> Septic Tank (Specify Requirements) .......................................-...........-----------........................_--..............-----------_.._..._------------------ . <br /> Disposal Field (Specify Requirements) .... -_ - -----_t----49_e ------T_ ...---- <br /> F. ._.._._:;P-,- <br /> , �.._. -" `- `~ -------------------------- <br /> -------------- -------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 /> By ..-- •-------------------------• • 2 <br /> Title .... ........................................ <br /> 1 . (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY4-2 <br /> _..---..... ..--•...................•-••••----•--••-----............-••--.....-- •.- DATE ...._ ...a w .1.�'-•_-.._. <br /> BUILDING PERMIT ISSUED .._____ _ DATE <br /> ADDITIONAL COMMENTS _ <br /> ......... <br /> -...................... <br /> ..._...-•----•--•--....._ �•--- _....-•------------.` --- ---------•--------.._._.............................. ---.......:_....--- --•---•------- <br /> ---------------------..............................•........... •-------------------...---•-------••--•---------•-------..... ---------------------------- -------- --- -----•--•--------- <br /> ------- ---- - - ------------ <br /> Final Inspection by . ........................-- ---.__...--•-•-------••- � ----------------- ---------------------------------------------------------------Date .. .7�.._._..- <br /> T.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �r <br /> E_ H. 13 24 1-'68 R,,, gm 7/72 3 m <br />