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FOR 6FFICE USE: F <br /> ar. APPLICATION FOR SAI)TATION PERMIT <br /> ----------- -------------------------------- Permit No. - <br /> S7o. <br /> (Complete in Triplicate) / <br /> _________--------------- This Permit Expires 1 Year From Date Issued 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 existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._ _+ _ Ir_�i1� ___f�----- UP,,_ ---el � Q- 1CS S TRACT -------------------------- <br /> ', f) <br /> Owner's Nam �6 �- /�-� - -------------------------------------- ----------- - Phone---T ._'_��.-_'.?�-_ <br /> Address ------- -GGT /�A4�_Q tQ47-'----------__ City 1 "l C ��' ---------------- <br /> R <br /> Contractor's Name ---- .l-r-- ��'1G-l --` -----------------------------License # - �-- ` Phone ---Ff <br /> " <br /> Installation will serve: Residence Apartment House'❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other -------'----------------------------------- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size � �� - � -------- <br /> Water <br /> __. .Water Supply: Public System and name ---------------------- ------------- ------Private 0. <br /> Character of soil to a depth of 3 feet: Sand'❑ Silto Clay ❑ Peat ❑ Sandy Loam •❑ Clay Loam ;❑ <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.) \n <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth --------------------,----- ki <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------------•---- i <br /> Distance to nearest: Well ____________________________________Foundation ______________________ Prop. Line ______________-_-_---_ <br /> LEACHING LINE [ ] No. of Lines ----------------------- Length of each line--------------------- ------ Total Length ------.----.---..:_.-__.-•-- <br /> 'D' Box ----------.- Type Filter Material ____________________Depth Filter Material .-------------------..__............... <br /> :.__. <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line __________________-_.___ <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --_- ------------------------------------- .....Rock Size -------------------------------- <br /> Distance <br /> ---------------------- -Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -------------!........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Qate __ __________________________J .-f- <br /> ,-�' <br /> Septic Tank (Specify Requirements) ------ Q ai_a------ _7- ------- - --- --------- - --____-- r: <br /> Disposal Field (Specify Requirements) ---------------------------------------------n-------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------=------------------------ <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 /> 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, 1 shall not employ any person in such manner I <br />{ as to become subject to orkman's Compensation laws of California." <br /> Signed -- _ . Owner <br /> BY ------ Title ------------ ---- <br /> (If oer thanow <br /> i <br /> ; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------A5�,' �_ fes_- _ ______________ <br /> -----------------------------------------------------------------------• DATE --------,j` <br /> BUILDING PERMIT ISSUED ------------------- - ------------------------------------=--------------DATE -------------------------------- <br /> -- ------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•---------------------------------------------------------------- --------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> ----------------------------------------- -- • ------ ----------------=------- <br /> Final Inspection b --'_--------- ---- --------------------------------------------------------- - - 14:/ - ---------- <br /> p Y� --------- --- -=-- ----- ------------------ Date ------ ----- � -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> f E. H. 9 1-'68 Rev. 5M. ' <br />