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` FOR OFFICE USE: <br /> { <br /> APPLICATION XOR SANITATION PERMIT <br /> {Complete in Triplicate) <br /> 1 Permit No. _-- --- <br /> ] L <br /> --------------- Date Issued <br /> � this Permit Expires 1 Year From 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 .-------679k------------- -----n ©Qfl�f CENSUS TRACT ---- -'-5 --• <br />' Owner's .Name /_ `�!�fl - }-- 17f :-------------,-y-=�----------------- -Phone <br /> Address ......13.01_&__ --=--l�_o----- C`A��Q�-------------------- City ----jo",-{---C4 ` <br /> -------------------------------- <br /> Contracto ' Nar�a --- --0t _Nt� ---------------------------•-=------ .License # Phorse <br /> � oymU -l� atirvdp: <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel [] Other f <br /> `�- <br /> --_.-- Number bedrooms. -3. .- f . �lNumber of living'units: ^� <br /> --------------------- <br /> Water Supply: Public'System and name ---------------------------------:----- ______Private [ � <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Gay ❑ Peat Sandy Loam 2- Clay-Loam E] <br /> - Adobe an <br /> Hard <br /> P ❑ ❑ -Fill'Material- _--_-!f-yes,�tYPe ---------------------- <br /> (Plot <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 seep pit permitted if public sewer is available within 200 feet,) ~ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK, Size_-_ `0 <br /> ----X•/------X-------------•-_ ----- Liquid Depth ......--- .....---------- <br /> Capacity _�pQ-, Type P/_jjF1-A_3_ Materia l_S�i..-A(C— No. Compartments --_- <br /> istance to nearest: Well }---_-------------------Foundation ---/0------------- Prop. Line - ..-______--_- <br /> LEACHING LINE No. of Lines --- ______________ Length of each line__----3w-Or <br /> Total Length ._--- Q..-.__-_- <br /> .` 'D' Box - Type Filter Material'R4_C_K. bepth Filter Material --------- - ---- `--__-_------------- ll <br /> C <br /> Distance to nearest: Wel! ----- -------- Foundation _1_0--------- Property Line -A4.................. <br /> SEEPAGE PIT [ ] Depth !--------------- Diameter ---------------- Number `--------------------------- Rock Filled Yes '❑ No 0i - <br /> Water,Table Depth ------------------------------------------------ <br /> Rack Size -------=-------- --------- <br /> Di stance <br /> •------- <br /> Distance to <br /> nearest. Well -----------------{---------------------Foundation ----------------------- Prop. Line ..------.-_-_.-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit F# ------ <br /> --- _ __________________ Date _-----_.---__--_--:---__--.-_---_-) <br /> Septic Tank (Specify Requiremenls) =---------------------- -------------------------=-------- ---------•-------••-----------------------•---- <br /> Disposal Field (Specify Requirements) - `•------------------------------------------------------------------------------------------•----------- <br /> ------------------------------------------------------ --------------------------------------- -------------------------- ------------------------------------ --------------------------------------- <br /> ------------------ --------------- ------------------- , - <br /> ----------------------------------------------------------------------------------- <br /> .::r {Draw existing and required addition on-reverse side) i! - f i <br /> 1 hereby certify that I have prepared this application and that the work will he clone in accordance with San Joaquin i <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 fallowing: <br /> "I certify that in the performance of th rk for which this permit is issued, I shall not employ any person in such manner <br /> as to become subje Workma Compensation lqws lifornia." <br /> Signed ----- - ---------- ----------- Owner <br /> By --------------------- -- ----------- Title <br /> ----------- <br /> other#han owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - 1 L R ------------- ----------------------------------------------------- ---. DATE __. .. -. L-`- , <br /> BUILDING PERMIT ISSUED ----- _ . .,.. DAT): - <br /> :- - --------- <br /> ADDITIONAL COMMENTS - = <br /> --------------------------------------------------------------- <br /> ------------- -------------------- -- <br /> ------- --=-- <br /> ---------- ---------- --------- --- ---- ----- ------- -- -- : ---- �:__ ' <br /> - --: � -,-- - - -- <br /> ------ --- ---------------------------------------------------- - ---- <br /> ------- <br /> Finallnspec Date -- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br /> E. H. 9 1-'6$ Rev. 5M j <br />