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Y' FPR OFFICE USE: <br /> APPLICATION„POR SANITATION PERMIT <br /> - Permit No.�_....-......._... <br /> (Complete in Triplicate) <br />_ .•. Rate Issued <br /> ........... <br /> ..... <br /> This Permit Expires 'I 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 /> I_-._.. ._........ <br /> �• = -�'� '.... .. CENSUS TRACT ................... <br /> JOB ADDRESS/LOCATION ....... <br /> Owner's Name <br /> ......... ..............:....................Phone ... .. <br /> 1 <br /> rr ...._... . --� -•-•-•--F . ... ............ .. <br /> Address ................... v� Q...$"...._...._ _.w- -�........ <br /> ................ City . •------- .._. ................................:._,........... <br /> --..License # � -: -'7... Phone T�b�.1��.�.7.. <br /> -�....�_-., .... <br /> Contractor's Name ......----•----• o:rr�.................•---...'. <br /> Installation will serve.- Residence) Apartment House❑ Commercial ❑Trailer Court 0 <br /> E Motel []Other .................�.... <br /> Number of living units:...._..... Number of bedrooms ._•__..Garbage Grinder ............ Lot Size .�. .- .x-II-._---.••••.....--• <br /> Water Supply; Public System and name --_----••-.-•-•--••-- •-. ••••••-•--------•---•------• ...... ......Private , <br /> Character of soil to a depth of 3 feet: Sand)] Silt❑ Clay ❑ ' Peat Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe Fill Material .......... - If yes,type ..............-• ------_---• <br /> k _X . <br /> (Plot plan, showing size of lot, location of.°system in relation fo wells, buildings, etc. must b4placed on reverse side.) <br /> NEW INSTALLATION- (No septic tank or seeQV <br /> %page pit permitted-if-pul lic`sewer-is-available within 200 feet,) �� S <br /> 1'i r /, <br /> . . ` ' ` g ) -_-. . Liquid <br /> PACKAGE TREATMENT � SEPTICTANK( j teril- u%111 NoCampo. <br /> CapacitY/� p Type rtments .. <br /> y <br /> . �".. <br /> _14- <br /> _. F.ounda`1 an - --�• .- *:Prop. Line <br /> Distance to nearest: Wel(g' °__ _�................. <br /> Q. Total Length - -_-• . ............... <br /> LEACHING LINT: Q No. of Lines .......s�..__._ .- <br /> 'L. <br /> te°� of each line- - :•-•---••- <br /> ,',Y -� Material ..... .......-----•. •---....:. <br /> D' 8oX..�✓ Type Filter Material _1. .. ._ Dep h F+Iter I <br /> { , <br /> Distance to nearest: Well _:. ©.•t`_._.... Foundation ..._T. .._�`........ Property Line ... ...-•--__-• <br /> SEEPAGE PIT j ] Depth __... Diameter Number ............................ Rock Filled Yes El No <br /> - <br /> Rock Size ..........:.....................Water Table Depth l <br /> Distance to nearest; Well:............... Foundation ........ Prop. Line -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____. Date ..................................) <br /> i --_... <br /> Septic Tank (Specify Requirements) ........ - ..- <br /> � <br /> Disposal Field (Specify Requirements) ........................................................-----------------------•-••--•...----...........------..... .. <br /> .._......__R..'_____________________------------------------------•...................._............._.....__.._._-_.....___.... . <br /> ................................................................ . <br /> ti..s ............... <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 /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in swch manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ••.................. Owner <br /> Et52J!-_ .......... ........... ...... ......... <br /> -A------- . Title <br /> --• <br /> (if oche t an owner) <br /> FOR )DEPARTMENT USE ONLY <br /> '-- APPLICATION ACCEPTED BY ..._ _:_ _ DATE .. �.•J 3-•-•_.._..,____•... <br /> ..... <br /> BUILDING `PERMIT ISSUED..... _ - � <br /> -- -• - -- <br /> ADD{TIONAL COMMENTS _..� �. .. _.rF1 •-• - •�i+� <br /> ::.....: <br /> . .: :...:..Dat :: .............. <br /> ............... ...... <br /> .., <br /> Final Inspection by: :-- t••• <br /> . . - SAN JOAQUIN_LOCAL' HEALTH DISTRICT _ 4r <br /> 7/72324 =-- <br />