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FOR OFFICE USE: PPLICATION -FOR SAN1 ATION PERMIT <br /> Permit No. <br /> r "f (Complete in Triplicate) f <br /> ---------- - t Date Issued _ ?� <br /> # I This Permit Expires 1 Year From Date issued . <br /> 4.2", ------ <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 ade in omplionce with County Ordinance No. 549 and a istin Rules and Regulations: <br /> r2t <br /> JOB ADDRESS LO�ATF ��! r�� IV <br /> ✓ ' CENSUS TRACT ------------�-- ---- -Owner's Name ` - V- - Phone <br /> -- -- --- -- - <br /> Address --------------�- = - ------------------��.! /r -'= --- ------- City --------------------------------- <br /> License# _.--------- <br /> ---- - ---- '- •....._ <br /> Phon <br /> Contractor's Name:.. --- ---- <br /> Installation will serve: Residence [] Apartment House❑ Commercial :❑Trainer Court 10 <br /> Motel ❑Other -__ - ---- I <br /> Number of living units. --------- Number of bpdro % '- <br /> s? Grinder -.--_____-- Lot Size _ ''-1/t- �" ------- <br /> Water Supply: Public System and name _-C-j—"L`--- --- --- ------------------------------------------------------------•----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Gay ❑ Peat❑ Sandy Loom ] Clay Loam:[] + <br /> p .. <br /> - Hardpan ❑ Adobe Fill Material ------------ if yes,type ------------------------- <br /> (Pilot-plan, <br /> ------------------------(Piotplan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.), r <br /> t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) _ +r , <br /> ' <br /> -PACKAGE TREATMENT [ SEPTIC TANK'X( Size_--X---�__ - ----- -Y------------- Liquid Depth --�------_---- --------�� <br /> < « <br /> k „ CapacitYAM- ----- Typeg� 'Material_-_-_ - -- -- No. Compartmentsc.----.)----r <br /> Distance to nearest: Well _____ __ ________Foundation - ---------.Prop. Line _._ ------ i <br /> LEACHING LINE [ ] No. of Lines ___- _f-- --------- Length of each in .__f ---.�- -- Total Length -- --�---- <br /> IA � ­1­17 �f s <br /> 1, D';Box Type Filter ,/�j�aterial __�.____------- epth Filter Ma�eriaProperty Line _ _.--. <br /> I Distance to nearest. Wel / `""� " S_ Foundation - _ <br /> I 0 <br /> SEEPAGE PIT [ ) Depth --- r"- Diameter - ._____ Number _____(---I----- f/--- Rack Filled Yes No i� i V1 <br /> j -____.-Rock Size __ Fes} <br /> Water Table Depth __�� -------------------- �---- ----------�,-------- � I <br /> Distance�to nearest: Well --_ - -- -- - ---- -------------Foundation . --- Prop. Line <br /> Ir REPAIRJADDITION{Prev. Sanitation Permit#'-"---------------=------------------------ Date --------------------------------=-1 <br /> Septic Tank (Specify Requirements) ----------- - ----- ------------------------------------•-----------:-----------------.---------------------------- <br /> fQis Field. ecif RequiremenW -- - --------- - -------------- ------ ---------- -- --------- <br /> s <br /> ------- - <br /> ----- --- ------ ------- ------------------------ ----------------------------- <br /> ( - <br /> raw istin and req it 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 i the perFormanm of the work for ich this permit is issued, I shall not employ any person in such manner <br /> as to bec a ubject to Work an's C pensat' laws of California." <br /> Signed Owner <br /> F Title <br /> ' --�''------ -- <br /> BY <br /> (If of er than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------ DATE ' _-"i------------- <br /> BUILDING PERMIT ISSUED ----------------- ------------------------ <br /> ----DATE -------------•---------• /I--•------------- <br /> ADDITIONALCOMMENTS -------------------- ---------------------------------------------------------- ---------- <br /> ------------- ------------------------------------------------------------------ ----------- <br /> -------------------------------------------- --------------- -- ---------------------------------------------------------------------------------------------------------- <br /> ------------ --------------- <br /> ----- <br /> -------------------------------------- -- - ------- -- - - - -- <br /> Final Inspection by: ------------ i-- - Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> t <br />