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J <br /> Y: FOR OFEECf.USE:¢1 APPLICATION FOR-,SQNITATION PERMIT <br /> ------------------------------ ----------------------- .Permit No: _ <br /> (Complete in Triplicate1•'�"'""""' <br /> ----------------------------------I----- <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 rnc; jb lia h �Qr s ;Nr�...54 a�,d existing Rules and Regulations: <br /> JOB AbbRE55/LOCATION / t_ '-- - • - a,•• W <br /> Co � -CENSUS TRACT _-- <br /> . <br /> Owner's Name D J/ �'4 -------- ---- ---- p Phone,, = <br /> � ii <br /> Address a , �-S' -J?" ------------------. C-Itl/' CJ9---------------------------------------------•- <br /> Contractor's Name ------ 1Y/ -----------Licenses-3 �__ Phone <br /> Installation will serve: i Residence ❑ Apartment House�❑,L�Commercial ❑Trailer Court ❑ <br /> .. Motel ❑ Other ---- 00091 �_ € <br /> i' <br /> Number of living units:___ __ _ Gar <br /> _____ Number of bedrooms __ _ ___ bage Grinder /f✓__ Lot Size -�� --- <br /> Water <br /> ____Private <br /> Water Supply: Public System'and name --------------------------------- -- ''-------------- <br /> Character <br /> ------- --- '-,-�a--------------------------------- -------------- <br /> Character of soil to a depth of 3 feet: Sand' iIt❑ Clay [1],, Peat❑ Sandy Loam ❑ Clay Loam '❑ <br /> Hardpan ❑ Adobe '❑ FillMdteriali ---------- if yes,type ---------------------------- <br /> ,i <br /> (Plot plan, showing size of lot, location of system in relation to' wells, buildings, etc. must be placed on reverse side) <br /> I <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted-if public }sewer is available within 200 feet,) <br /> �`�r !',r 9 ' l� " <br /> [ ] �� - --[� �'���Nlaterial.�X � - -------- Liquid Depth�"J�-----------------• <br /> PACKAGE TREATMENT Ca azEPTIC TANK' T e Size___,,__ "_--_ ____, � <br /> p Y YP `°------------------- No. Compartments ....... <br /> Distance to nearest: Well ___ !�_______________ _____Foundation f�-_--_- - Prop. Line __ �. <br /> LEACHING LINE VflNo. of Lines -------1-------------- Length of_.each line. <br /> -------------- Total length X0.0------------------ <br /> 'D' <br /> -----_.------'D' Box ------------ Type Filter Materica kMepth Filter Material ------------------------------------ <br /> Distance to nearest: Well -at -------- ----=Founcicitloh -----_----_----_ jj -- Property Line ----- <br /> ---------------- <br /> SEEPAGE <br /> ` ---- - .SEEPAGE <br /> PIT [ ] Depth` I ) <br /> }-------------------- Diameter _.__ _--�_ -�Numbers.,-------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth -------------------------------------------------Rock Size ------------------------- ----- <br /> Distance to nearest: Well ______________"_____I____ t_______-Foundation ___-__-____-___-__ Prop. Line __-_--____________.___ <br /> , <br /> REPAIR/ADDITION(Prev. Sanitation-'Permit# ______"-__-_---"---------_---: __-!._._-_fbate __________________________________) <br /> SepticTank (Specify Requirements) ----------------------------------------------_ j------------------------------------------"------------------.--------------------------- <br /> Disposal Field (Specify requirements) -------- -------------------------- ---------------- -------- ------ <br /> ----------------------------------------- -------- <br /> ---- ----------- --------- '` -- ------ --------------------------------------------------------------------------- ------------------------- <br /> s -------------- <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 Workman's Compensation laws of California." <br /> Signe -------------------- n -- ----- ---- --- -------_, ------------------ Owner <br /> B _ •✓' Title //--'c-�'•' <br /> (If other thaowner] 1 I <br /> k i <br /> FOR DEPARTMENT USE ONLY <br /> _ } I ] `f ---- -------------- ----- ---------------- DATE _-6 � <br /> APPLICATION ACCEPTED BY --- c_ � _---- ------------ ---------____-- <br /> BUILDING•`PERMIT •15SUED -----'� --— - - - --- -� -.:"-------------------=-•---------._DAT '-..------------'�----- =------'"-----• ; <br /> -------------------------- ---- - --- <br /> ADDITIONAL COMMENTS --------------------- ------;= -I--------------------------4 € , �� ;-------- ------- ----------- <br /> _�. _ __. - — - __. _�. ---_ _ _.. - <br /> - ---------------------------- <br /> --------------- -------- -- - _ - --------------------------------- ------- <br /> ------------------------------------------- ------- <br /> { �q <br /> Final Inspec7ro ----- --------------------------Date _ .._£�-`:!/-`- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E, H. 9 1-"68 Rev. 5M <br />