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FOR OFFICE USE: -_­APfLICATION FOR S ,NITATION PERMIT r <br /> CkAo (g---------t i cr° 9 <br /> A Permit No: <br /> "v (Complete in Triplicate) <br /> This�Crmitfxpires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health MT3-F-;� for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Oredinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . - ''� ' /--- ----------------- ------------ -----CENSUS TRACT -------------- ----------- <br /> Owner's Name ------h�--------- -------- ------------- -----Phone ------------------------------ <br /> Address ----Z-3-r-47-9----- - ------------------ Ci .57 7Z)_a _77 -----------------------------•------ <br /> Contractor's Name / C_-----------License # 0?47322� Phone <br /> Installation will serve: ResidenceXApartment House-E] Commercial :❑Trailer Court ❑ <br /> Motel ❑Other ----------------------------------- -------- <br /> Number of living units:__- --- Number of bedrooms ---_- __Garbage Grinder `- Lot Size - - -_ �or ..r.-._ <br /> 1 <br /> Water Supply: Public System and name ---------------------- ----------- ---------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> i <br /> Hardpan ❑ Adobe Fill Material ------------ If yes,type -_--_--___-______________ <br /> a <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'[ Siz y�e�= x-- ---------- -------- Liquid Depth -__'/-`X-__---_--_- <br /> 1'4, A4, 77iiv Capacity -4_,_- T e - Material_�1 No. Compartments ------------------- - <br /> c, 9fJf�rvl A ty YP P f <br /> i <br /> l�/i/� Distance to nearest: Well _____,�Q___________________Foundation ___��-__-_-___ Prop. Line _-____�..__.___.._ 1 '� <br /> LEACHING LINE No. of Lines --------�------ Length of each - -- Total Length .__-11A--e.-.___-.__-_ <br /> 'D' Box --�---- Type Filter Material,'- _Depth Filter Material --_----,_2_________________-._-__-.- <br /> Distance to nearest: Well ..- ..... Foundation / ---__-__-_ Property Line ---__- ._._- ._. __ <br /> SEEPAGE PIT Depth __AP__�--__-_ Diameter'y�e�sW��Number _________/_______-____ Rock.Filled Yes No 0i <br /> .� of <br /> Water Table Depth -- -a ------------------------------------Rock Size ----=9?X_, ----------- <br /> Distance to nearest: Well --14-4-__________________---._-Foundation __if.-___.---- Prop. Line ..4__..._.._. <br /> REPAIR/ADDITION(Prev. 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Counjy 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 /> "ilk*rrtify'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 /> Signe -------------- -4an <br /> -----------}----- -- - ----------- r <br /> By (If other wner)� <br /> OR DEPARTMENT USE ONLY � <br /> r <br /> APPLICATION ACCEPTED BY ... i ----------------------------- DATE ------ <br /> - <br /> - - -------------------------------- <br /> BUILDING <br /> ` • <br /> -- <br /> BUILDINGPERMIT ISSUED ------ - - ------------------ ----------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------- ---------------------------- --------------- --------=--------------------------- <br /> - ------------------------ ----------------- <br /> --------------------------------------- ----------------------- <br /> --------------------------------------------------------------- ------------------------------------------ -------------------------------------------------------------------------- <br /> ---------------------------------- <br /> ------------------ <br /> Final Inspection by: <br /> --------------Date <br /> SAN JOAQUIN, LOCAL HEALTH DISTRICT <br /> j <br /> -E. H. 9 1-'b8-Rev. 5M <br />