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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> :......:........... �..._ <br /> (Complete In Triplicatel Permit No. _..7 7"-�. <br /> 4.. •/, <br /> •...................... ....• This Permit Expires 1 Ye- <br /> ar From Date issued Date Issued <br /> Application Is hereby made to the San Joaquin Local Heat b�strict`for a permit to construct and Install the worst herein <br /> described. This applicatlo„ maple c Xnpllance vyith Co�ince 5A9 and existing Rules and Regulationsr <br /> JOB ADDRESS/LOCATION . �.�.---r -•-- ...................�•C`. .:.-CENSUS TRACT .............. <br /> Owner's Name ..._..... ._ /.., <br /> ................ S f� <br /> ............. .....Phone <br /> Address ..... _�.9in <br /> _f�_­� . Ci p-�.. <br /> city �."e-�.._.. <br /> ....................... <br /> Contractor's Name --- <br /> ------------ <br /> -----------_--------- ...........License # �$X�, Phone . ? <br /> installation will serve: Residence Apartment House 0 Commercial[(Troller Court <br /> Motel ❑Other <br /> Number of living units:----!__.__ Number of bedrooms__...-._ <br /> Garbage Grinder ___ ........ Lot Size <br /> I <br /> Water Supply: Public System and name ------------------------ <br /> --------- -----------.......... --- . PrIvoteA O , <br /> Character of soil to a depth of 3 feet: Sand C3 Silt a Clay 0 Peat❑ Sandy Loa Clay Loam 0 <br /> Hardpan Adobe O 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 seyyer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f } Size.jJ(f�.lzm j -------•---.-•-__---- Liquid Depth _..------...... .......... <br /> Capacity Type ------- Material--------- =•----- No. Compartments <br /> yQ Distance to nearest: Well _...._..-•--------------------- -- Foundation ---_-.--- _----- -•--. Prop. Line .._...--..•- - <br /> / =.... <br /> LEACHING LINE [ ) No. of Lines -----I --------------- Length of each line------I.C/0-_----.-----. Total Length ....._S/.�•.. <br /> ............. l <br /> 'D' Box .........-.. Type Filter Material .---------_----...Depth Filter Material ...................... <br /> ,fG&A j4 g Distance to nearest: Well ........................ Foundation ...... _ . ........._... Property Line <br /> ..................... <br /> T { 'Ciawwbr -__----._._.__. Number ....... ............. Rock Filled YesXj No <br /> Water Table Depth ------•--------------- = -- •--- •••--Rock Size <br /> . <br /> Distance to nearest: Well .__.. �'+ ....................Foundation Prop. Line .......:..:....... <br /> REPAIR/ADDITION(Frau. Sanitation Permit# ---•-.•.._....... <br /> .......................... Date ------ ............. <br /> Septic Tanis (Specify Requirements) - .1 r," <br /> ........................f._....... ...._.......»-•-- .. .. <br /> Disposal Field (Specify Requirements) .. ---_..... <br /> i <br /> ----------------- <br /> rt - <br /> t �. <br /> ` ---------- ---------------------•-- --------•-•-•.._....................... <br /> -------------------------------- 4 <br /> (Draw existing and required addition on reverse sidel <br /> -'I°heretsy certify that I`have prepared this application and that the work will be done In accordance with .Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or licen. <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which t permit is Issued, I shall not employ any person In such manner <br /> as4ed <br /> sub cY o Wo an's C ensat'on laws ifornia." <br /> Si,g ..._... <br /> t- -- ------ Owner <br /> BY Title <br /> 1L�---- ------------------------------ <br /> (If other than owner)- - <br /> ° F DEPARTMENT-USE ONLY <br /> APPLICATION ACCEPTED BY 5- - -- ---- -- ---- - <br /> ------ ........' DATE_.. <br /> BUILDING PERMIT' ISSUED .-- <br /> - <br /> ----•.-.- ----- -- -----.._DATE ................... ...'-- <br /> ADDITIONAL COMMENTS - ------- �-----...-_-.------------- - --•--- - <br /> -------------- - .-'--- <br /> Final Inspection by- - ------ -- -- --- --- <br /> - --- -- -------- ------- ------- ------ - - ------.Date ... .. <br /> EH 13 2!t 1-6 y <br /> 1 SA JOAQUIN LOCAL HEALTH 'DISTRICT 4 <br />