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FOR © Ff iG USE, <br /> APPLICATION FOR SANITATION PERMIT ��_63 z <br /> Permit No. <br /> .............................. .................. ... <br /> (Co nsplete in Triplicate!- :.... <br /> ...................... .. .. ................. _ _. , `Date Issued <br /> This Permit Expires i Year From Hate Issued <br /> ........... .. t <br /> f Application is hereby,evade 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 <br /> existing Rules and Regulations, <br /> .TOB ADDRESS/LOCATION . `..� .. .. � tG•`-...CENSUS TRACT ...:...................... <br /> Owner's Name ..... ............... ................ ..... Phone ............. .... <br /> l�}1`���'��~-- '"' 44 �: *�=- .........._.... sty ..... <br /> Address <br /> n/3 ....License # Q --�y---. Phone 1e:.171_045 <br /> Contractor's Name,-a►�s�+. -r--••- ....................................... <br /> Installation will se @3r� Residence rt[nentHouse a Commercial [)Trailer Court ❑ <br /> ` Motel ❑'Llther'-�:�:- = -ti - ............ <br /> Number of.living units::.:.-.. 'Num_ber of bedrooms _...._Garb a Grinder Lot Size .................. <br /> Water`Supp1Y= Public Sys and name € -• - •----- - ...........................................Private�--�— <br /> - - -- <br /> � -1' <br /> Character'of soil to a depth of 3 feet: Sand d Slit I] Clay ❑ Peat❑ Sandy Loam❑ Clay Loam ❑ <br /> Hardpan❑ Adobe j�FIOI•.Materlai ............If yes,type............... ........ ... <br /> $Piot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reversb side. <br /> r NEW INS_TALLATIONs (No septic tank or seepage pit permitted if public sewer is available within 20fl feet,) <br /> f Size ... Liquid Depth . <br /> f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK� j '...........:........•--.. <br /> ° Ca ciy7�Q Material__ - No. Compartments ----•-- <br /> r.,/1`0" r l ._. Pro tine ... _ <br /> • € Distance to nearest: Well:--fpf- :: ----... ....Foundation . ------- <br /> _r Total length ,, .i i..... <br /> LEACHING LINE [ I No. of Lines ,--...----•-....... Length of_Go line ....--•--- 1 .... <br /> ; D''Box�• �Type.,l;ilter'Mater� la .. ...Depth Filter Material 2,e.9................................ <br /> ,s Distance o e rest, Well ice.: ............ Foundation ............... ......- Property Line ...............•....... <br /> 3 <br /> .. hock Filled Ye; ❑ No <br /> Number <br /> SEEPAGE Piz [ � Depth, _�":'.`.:..-.�..:.... Diameter ................ ....-----...........----.. <br /> Heater Table Depth ..... ......................................Rock Size -..... ..__.,....._...... <br /> `9 Distance to nearest, Well ..:........................Foundation .... .Prop. Line <br /> REPAIR/ADDITION(Frau. Sanitation Permit ............................................ Date ............. ._.............- <br /> Septic Tank ISpecify Requirements) -•................................ <br /> ........................ . .:......_ ..................................................... _...�... ......:... ... <br /> Disposal :Field )Specify Requirements) -- . ..... ..r:..................... .............. . ......... .• ............ <br /> ' ...--•---••-••--•-- . -.- --_ <br /> ------_-------•- ------------.-----*................ ...... . ............ ._.. <br /> ............ ..... ..... ...........I --._.._........ <br /> ... -- .. ...... ......................................•........... .... <br /> (Draw existing and required additions on reverse side) x.. . <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> t County Ordinances, State Laws, and Rules and Regulations of theF San Joaquin Local Health District. Home owner or Iicen- <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 no! employ any person in such manner <br /> as to becarn subject to Work on's Compensation Talks of California." <br /> t _ <br /> € --•- Owner <br /> Signed . } x,.A.. .- •............................... <br /> e <br /> By ..........................................::......................-......... . ... - lite . <br /> Iif other than owner <br /> DEPARTMENT USE ONLY <br /> i - <br /> APPLICATION ACCEPTED BY ........... ..........._.. DATE <br /> BUILDING PERMIT ISSUED DATE <br /> ................. <br /> ADDITIONAL COMMENTS ... ................. ....................................................:............ .............. ........ ........ <br /> OMMENTS ........ ............ <br /> -------------•••••---.........-- .................-........................................................._.................................... <br /> ............. .... ... <br /> .......................... ........................ ............. <br /> ....... <br /> r� ..Date .'} _ ........-... <br /> Final Inspection by: ....c -. --- •- ._---••..................... <br /> EH 13 2h 1-60 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT /71t 3M <br />