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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> :.._.,_ <br /> ..................1 -. :S 3t <br /> - IComplete in Triplicate) <br /> Permit No. ..;.�.... f... <br /> ?..............I............ <br /> :7 <br /> ............................................ This Permit Expires 1 Year From Date Issued <br /> Date Issued .�..'�.`� .. <br /> "A) : 25.3 <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 /> M <br /> JOB ADDRESS/LO ATION :.....................�' �` l _( !........... ... : -:'_._.................CENSUS TRACE` <br /> Owner's Name C�� Q .+ ..5 t.... Q.. t�.s:�' c..� .. ...... '..��. phone+., ......1...........I............ <br /> i Address ..................710-2?/--._.--VI/......L.0Vn_1=....... •••....City <br /> Contractor's Name``--: ..License # Phone <br /> 1 11 <br /> Installation will senvd: % Residence [] Apartment Housed Commercial oTraller Govrt,'e-. <br /> Motel ❑Other .............. .......................... r <br /> 4 <br /> ;. Number of living units:............ Number of bedrooms .._.�L......Garbage Grinder ..&. Lot Size ........... <br /> I # <br /> pP Y Pucbli's System and name -- = .: �_-. <br /> :Water Su . : :. Private ®� <br /> t Character of soil to a)depth of 3 feet: Sand n Silt❑ Clay`C] Peat❑ ..5andy Loam fl Clay Loam <br /> Hardpan Q Adobe-i] Fill Material ............'If yes,type ... ................... <br /> (PlotIan showin '' <br /> p g� 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 seeps pit permitted if public sewer is available within 200 feet,) t� M <br /> PACKAGE TREATMENT [-3- SEPTIC TANK Size.: q p <br /> X. ._.._.. Liquid Depth. <br /> --------•-••. <br /> 0-Caps sty .....---© _... Type .�}E� Materiol(K�C �. . o. Compartments Z- . <br /> } tante to nearest: Well .....,�� � .. ... Foundation .../D. ~_ Prop. Line <br /> ` l <br /> r <br /> LEACHING LINE [ No. of Lines ......./................ Length of each line.__...-7 ._..------ Total Length .. s............-. <br /> S' ... Type Filter Material L -- Depth Filter Material . . .1.. ...��.............. <br /> � D'.Box . .. � � , . . _ {.. ..... <br /> istance to nearest: Well ._,2).... . Foundation ....' ...... Property Line S <br /> SEEPAGE PIT Depth I ._..---.Diameter-Y_X Number:-.-1-- hock Filled Yes No C <br /> I Gr r /f <br /> i Water STable Depth ........ Rock Size .�..a ... ` .. - <br /> Distance to nearest: Well ...-1.©a`4 =--. ridbtlon -__..__.... Prop. Line ...... <br /> t'. REPAIR/ADDITION(Prev. Sanitation Permit ....................................... Date .................._.....----.----.y <br /> SepticTank (Specify Requirements) ...................-•--............................. ...................................._................................. <br /> Disposal Field {Specify Requirements) ._.,---_---------_ .......................................... ...............­7 <br /> - a <br /> ............................................------- ......_......---•-----------------------......_1......__._..........._............_........ <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 far which this permit is issued, i shall not employ any person in such manner <br /> as to beta a subject to Wor man's Compensa on laws of California." <br /> Signed .. . ... ._. . .................................... Owner.. <br /> �-' :... title : <br /> Y ----- ----.. ...._...... ......................................_........................... <br /> (If other than owner) : <br /> FOR DEPARTMENT USE ONLY <br /> ` <br /> APPLICATION ACCEPTED BY ....... :..5 .. ......�...................... <br /> ...•--•---------- --------=---------------- ............ DATE �.- � . f <br /> BUILDING PERMIT ISSUED --•..............:......................:::---.........._...------------=......---DATE ....... -----•--•------ <br /> ADDITIONALCOMMENTS .......... ................................. .............................................................. ................................................. <br /> ( <br /> .......................................... <br /> ._......-•---•..... ............... ................................................ .. .. ..... ... ......---........................................................... <br /> --------•..............I..._._. .... <br /> ........................ .............. .. . .. - :.... . ..... <br /> Final Inspection . -- ...... .... ..............................................Date , j-. ... ................. <br /> SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> . .t.t - rl�z.��M �" <br /> 13 24_1-- G8._Rev.5M--; , <br />