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FOR OFFICE USE: <br /> OW $ APPLICA74ON QOR SANITATIO RMIT <br /> ------------------- ------------------ ----------------- <br /> '3-(� (Complete in Triplicate) Permit No. ...... <br /> - <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued <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 existingRules and Regulations. <br /> JOB ADDRESS/LOCATION .rS�'Yr,?�Il__ 1'fi '/v!_ ._42LUQI' __�t[�LL�_(/_q�_0 _ ___CENSUS TRACT -------------- -----_---- <br /> Owner's Name _ .125------f-_.-U-�,-------�_Q__b /✓--I----------------------------•----------------- -Phone `367--- .----- <br /> Address ------ <_P12LVE------ city <br /> / __----------------------License rlt� JIB .UInN.CPhto7n`eContractor's Name .___ <br /> Installation <br /> will serve: Residence fKApartment House❑ Commercial []Trailer Court !❑ <br /> Motel ❑Other <br /> Number of living units:-----r_-_- Number of bedrooms .-�-.Garbage Grinder ------------ Lot Size ____________________________________________ _ <br /> Water Supply: Public System and name ------------------------•------------------------------------------------------------------•--- ---------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,W. Clay Loam E <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 tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size------------ _-___-__________________ ------ <br /> Liquid Depth ______--__-_.__.___-___- <br /> Capacity -------------------- Type -------------------- Mat rial--------------- ----- No, Compartments ...................... <br /> Distance to nearest: Well _____________________ __________Found on ____.._____.____.___ Prop. Line ______________________ <br /> LEACHING LINE [ ] No. of Lines _________________-_--__ Length of ch line______ _________-_____-___ Total Length __.-.-__-..._-._-__-_-__ <br /> 'D' Box .-________ Type Filter Material ------------------D pth Filter Material --__------------------------------ ----- <br /> Distance to nearest: Well ______________ ________ Found ion ------------------------ Property Line ------------------__ n <br /> SEEPAGE PIT [ ] Depth --___-___-_-_-_-_ Diameter _______________ Nu er ___ ----------------------- Rock Filled Yes '❑ No <br /> Water Table Depth ------------- ----- -------------------• ------.Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... C7 <br /> REPAIR/ADDITION(Preva Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ____________________________________________________________ <br /> ---------------=------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I 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 Work an's Compensation laws of California." <br /> Signed ---- ---------------------------- •-------------------------- Owner <br /> By ------ --- -----�'�----------------------- Title ------------------------- ------------------ ---------------- <br /> (If other than owner) <br /> FOR DEPARTMENT, USE 94LY <br /> APPLICATION ACCEPTED BY ------------------------------------------ ------- - -- -- -- DATE �j=�o�=? •------------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------------- ----- ----- -- -=---------- DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------- -- -----------------------------------------------------------------------------------------•-------- -------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - - ---------- ---------- <br /> ------------------------------------------------------------------------------------------------------------------------ ----- <br /> Final Inspection by: ------ <br /> --------------------------- <br /> ---- -- -- ---- - <br /> Date = =�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />