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FOR OFFICE USE: <br /> ------------------------------------------------------- -APPLICATION FOR S ' <br /> - ------------- --------------------------------- ANITATfON PET <br /> ---------- ---•--------------- -- V, (Complete in Triplicate) Permit No, <br /> - <br /> --------------------------------------------- <br /> ----------------- <br /> ThIs.Permit Expires I Year From Date Issued Date Issued <br /> 11 P <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 ADDRESSAOCATION __/­�-_4 <br /> Owner's Name ---CENSUS TRACT <br /> _1W 0 <br /> Addre S .0, -------.Phone <br /> ss <br /> py <br /> Contractor's Name 07&w---------- city R-4— --------------------------------------------- <br /> ----- -------- ---------------------License '/Iftolri e <br /> Installation will serve: Residence 1K Apartment House C) Commercial fTrailer Court ------- <br /> Motel El Other------------------ <br /> Number of living units:___ _____.__ Number of bedrooms -r <br /> _1___ .....Garbc�ge Grinder ------ ----- Lot Size <br /> Water Su' ----- ------- <br /> Pply: Public System and.name ..................................—---------------------- =-----•------------------------•-------Private <br /> Character of soil to a depth of 3 feet: Sand El Silt <br /> 0 Clay 0 Peat Q., Sandy Loam it Clay Loam.[] <br /> Hardpan 0 Adobe 0 Fill McIterial NO.- If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to,wells, buildings, etc. must be place-d on reverse <br /> NEW INSTALLATION: (No,septic tank or seep . side.) <br /> V_T age pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size- <br /> ------- - <br /> --------------------------------- �iquicl Depth --.-------- <br /> P tY <br /> -------- <br /> pacity -------------------- T e -------- ----------- Material--•------------------- Na. <br /> Compartments ...... <br /> Distance to nearest: W 11 -------------------------------------Foundation ------- <br /> LEACHING LINE No. of Lines ------ ---- Prop. Line ------------- <br /> 'D' Box ----- Length of each line------------ --------------- Total Length ------- L............ <br /> Type Fi Ver Material --------------------Depth Filter Ma rial <br /> SEEPAGE PIT Distance to nearest: Wel� ------------------------ Foundation -------------- ---- --- Property Line --------- .............I <br /> Depth -------------- Dia eter ---------------- Number ------------------------- --- Rock Filled Yes No .Ej <br /> Water Table Depth -'.7---- ------ ------------------- <br /> --__,_-------Rock Size --------- <br /> Distance to nearest: Well <br /> ----------------------------------------Foundation ------ ------- ---- Prop. Line _.,................... <br /> REPAIRADDITION(Prev. Sanitation Permit# ----- -------------------------- Date ...... <br /> Septic Tank (Specify Requirements) --------------- <br /> --------------------- <br /> --------------------- ----- -;,-v------ ----------------------------- <br /> Disposal Field (Specify Requirements) -------7,d.4U----------- <br /> _7_74 -e <br /> ----------- <br /> Akoi--------- <br /> ----------------------------------------------------------I------------------- <br /> ------------ <br /> - - -------- ---- <br /> (Draw existing and required addition a-n reverse- - -- side)-------­-------------------- --------------------------- <br /> I hereby certify that I have prepared this application and that the work will be clone i.n 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 suble to Work n's Compensation laws Of California." <br /> Signed - -------------- -- -------------------------- <br /> By ----------- Owner <br /> other than owner) - -- --- -- -------------------------- Title ----------- ------- <br /> ----------------------------------------------- <br /> - <br /> FOR -DEPARTMENT USE..ONLY <br /> APPLICATION ACCEPTED BY ------ --------------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED ---- -----7,�_Z�Qn7 <br /> COMMENTS ---^-----------------------------------------------------i_--------_DATE ------------- <br /> ADDITIONAL COMMENTS ----------------------- ------------------------------ <br /> ---------------------------- .. - j---------1------ ­---------- ------------------------------------------------------------- <br /> ------------ ------- -------------------- -----------------*-- -----­------------- <br /> ---------------- ------------------- -----I------ ---- - -------- --- -- ---------------------------------------I--------------------------------------------------------- <br /> --- ---------- ------ --------------------- ­-------------- <br /> ------------- - -------- ---------- - ------------------------ ------------- <br /> - <br /> Final ------ <br /> Final Inspec'N --- ------------- -- ----- <br /> 7 7_--------------I--------------------- <br /> ..... ----- <br /> ---------- ---------------Date <br /> SAN JOAPUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />