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f p�� � <br /> FOR OFFICE USE: [ �� Ci C.O L � c/ G C'y ` <br /> APPII ATIC FOR SANITATI N PER <br /> - ---- --- ------------------------_ Permit No: - `_777 <br /> {Complete in Triplicate} <br /> - - -----_-_--------_---_ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> -------------- ---- -------------- <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 <br /> made in compliance with County Ordinance No. 549 and existing Rules and Regulations: J, <br /> f <br /> JOB ADDRESS/LOCATI N l�_� -± �''-°_"' - ' 1 " ,�5 CENSUS TRACT -------------------------- I <br /> f Owner's Name - Phone y 1 <br /> - - --- <br /> 11 <br /> Address ---------------------------- <br /> --------------- -------------- -----. City, �- <br /> '� - -- ` <br /> Contractor's Name --- --- r -- --------License # t <br /> Phone -------------------------- <br /> Installation ---- <br /> will serve: Residence (�artment House,❑ Commercial Trailer Court ;❑ - <br /> Motel ❑Other ---- _/�-------------------- - <br /> Number of living units------ Number of bedrooms ____l'- 'Garbage Grinder ----- Lot Size __- --------- --- <br /> Water Supply: Public System and name ___ - - <br /> pp Y Y ---------------------------- ----------------- ------------------------� .-------------------- --------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay E] Peat E] Sandy k oar E] Clay Loam EJHardpan F]Adobe Fill Material -----------4' <br /> yes,:type�___r _ ,_________ <br /> ----'e e - - . <br /> (Pilot plan, showing size of lot, location of system in relati...-on 'to wells;buildings-- -J-�, etc. must be`placed`on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f I SEPTIC TANK [df ------ Liquid Depth-f_______________________ <br /> Capacity z ____ Type- �_ Materia!_- -1�- s' No. Compartments <br /> Distance to nearest: Well --- o+� _'�_ ___________Foundation _____1_p--�___-_- Prop. Line ____S____�_--_--- <br /> LEACHING LINE [&I/ No. of Lines _ _-_. _#�._ ._="Length of each line"_�_.-6o__`-___ ---_____________ <br /> 'D' Box . - Type Filter Material Depth Filter Material ----Zf----------- -------- <br /> to nearest: Well ----- -- Foundation _-_-----/_ ___---- Property Line !.'�-------------------- <br /> SEEPAGE PIT - [ Depth __ S _--_- Diameter -�_ _ Number ;-___-_ _� ! ) �_ ----- Rock Filled Yes T__"No 0 <br /> Water Table Depth -------------------------70----------------Rock Size <br />' Distance to nearest: Well ------------IC00-`-----------------Foundation -----L0_-`------ Prop. Line .!;F----------------• d <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------_.----------} <br /> Septic Tank (Specify Requirements) ------------------- ---------------------------------------------------------------------------------------------------------- ------- <br /> Disposal -Field (Specify Requirements) --------------------------------------------------- ---------------------=------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------ <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 /> "1 certify that in the performance of the-work for which this permit is issued, I shall not employ any person in such manner <br /> F as to become subject to Workman's Compensation laws of California." <br /> l.. <br /> Signed ------- Owner <br /> -------------- ------------------------------------- <br /> By --------------- Title -_14flI±., ----------- ----- -- ---------- <br /> (If other than owner) <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . --------------------------------- DATE ' ' - ------_--------- <br /> BUILDINGPERMIT ISSUED -------- ---------------------------------------------------------L-------------------------------- -----DATE ------------ ------------------------------ <br /> ADDITIONALCOMMENTS -------'----------------------------------------------------------------------------------------------------------------- --------- --------------------------- <br /> I ------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ------------------------ -- --- <br /> ----------------------------------- <br /> -------------------------------- --- <br /> - - - -- -- --- -- <br /> Final Inspection by: - Date ------ - `� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E- H. 9 1-'6$ Rev. 5M <br />