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, ., <br /> FOR OFFICE USE- - -----------: FOR OFFICE USE: <br /> APPLICATION SA ITATION PERMIT Permit No. <br /> ------ <br /> -------- - -- - -- ----- ---- - --- <br /> �" {Complete in Triplicate) <br /> _ <br /> ,__ ` --) ` C .r : .. ✓ Date Issued.37:�l- --- --- <br /> ------------- --------------- <br /> -7-----_---- ----------------- ---- ---.-- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin.Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Or inance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION------ ------- � y���, ----------------- -------------..,-CENSUS TRACT--------------------------------. <br /> Owner's Name- -----_-------- p � :----- —------------------ --------- --------t------------ -- ------Phone ----------------------------- ------- <br /> --------------------- <br /> Address <br /> ------ <br /> {Address---- .- -------- ------City, r <br /> -----Zip---•---------- ------- ------- <br /> ------------ <br /> ------ <br /> Contractor's Name {I"' /"`V" �` --- .-------License #.. 7------- Phone_`7- ��.� - <br /> n <br /> Installation will serve: Residence E] Apartment House ❑ Commercial Trailer Court ❑ (J c� <br /> i <br /> Motel ❑ Other----- ---:------------------- ---------------- <br /> Number <br /> ----- --------Number of living units:_..............Number`of be . ooms--..;...____Garbage Grinder------------Lot Size----- fY. a_"--J----==-------------- <br /> Water Supply: Public System and name-:.!_. r <br /> - <br /> �-, , ` � = --.- -------------------- ------------------------------------Private ❑ <br /> .__ _. � �"` � i <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ !Clay Loam ❑ Q <br /> Hardpan ❑ 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 tan or seepage pit permitted if public sewer is available within 200 feet,] _ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth_------------------------ <br /> ♦ <br /> Capacity -------- = -------TYPe ------ Materia) No. Compartments <br /> Distance to nearest: Well ------------------------...----------------Foundation---------------;----------Prop. Line--------------------------- <br /> LEACHING LINE [ l No. of Lines----- i---------------------Length of each line.-----------------------------Total Leingth ------------------------ --- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material---------R-__-----.------------------------------------------- <br /> Distance to nearest: Well__.-___----_ ------------Foundation----------------------------Property Line----------------------------------- <br /> r Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth----------------Diameter--_-- -:----------Number--------------------------- ❑ <br /> WaterTable Depth---------------- -- -------------------------------.Rock Size------------- ---------------------------------- <br /> .Distance to nearest: Well------------------------------------- -----.Foundation--------------- -------- Prop. Line----------.----------------. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------- --------------------------D t ------- -_-.. 1 <br /> ' r � <br /> Septic Tank (Specify Requirements).--- ------- ---- ------ -------------- <br /> - -------- - <br /> --------------------- <br /> Re uirements}...._. _ _ <br /> .............. _,__- _-_-------------------------------------------- <br /> --------- <br /> Dis osal Field (S ecif <br /> -}--------------------------------------------------------------------------- ----------- <br /> -------------------- <br /> I ------------------- <br /> ------------------------------------- -------- ------------------- --------------------------------------- <br /> 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 County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> 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 as <br /> to become subject to Workman's Compensation laws of California." ! <br /> Signed----- --- -------1 --1 - ------------------------------ ----- --Owner <br /> BYt ----------------Title----- ,/� - - ------------------------------- <br /> If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED..BY n' -- %a' ---DATE..d ....... 7------------------- <br /> DIVISION OF LAND NUMBER. TE--- ---------- <br /> ADDITIONAL COMMENTS----331,5'//7]---------'y� __ '1 -- ------ <br /> f <br /> - <br /> ------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------- ------------------------------------ <br /> 4 <br /> -------------------------- ------ -----'f <br /> Final Inspection by: Date. /J+'7 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M <br />