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FOR OFFICE LISE.- <br /> r r�� _ APPLICATION FOR SANITATION PERMIT <br /> ermit No. C—s77 <br /> lCom p fete In Triplicate) ' <br /> .....:. This Permit Expires I Year From Date Issued Dale 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 apptitation is made in compliance with County Ordinance No. 549 and existing Rules and Regulotionst <br /> 409 ADDRESS/LOCATION ( . s; ...-•---•..............................:................;....CENSUS TRAcr --- <br /> ,Owner's <br /> _.,Owner's Name <br /> .........:...........•-s--- . - -; . , ...----... ......... ......Phone ..�..�...71.y.7.$:'L.._ <br /> Address .. _p�- f sZ�_ ::SG[�rlT,e�✓. .....--...................•............City ............. ........................................ <br /> Contractor's Name _ � �_ - ............:.......License # Phone }70Q Q1s?. <br /> Installation will serve: Residence Apartment House 0 Commercial❑Trailer Court ❑, <br /> Motel ❑Other <br /> .Number of living units:_4.W__. Number of bedrooms .__ Garbage Grinder Size ••_________ .............. <br /> Water Supply: Public System and name .............................................--------.- --•-----------•-- ............... Private i <br /> Character;sof,soil to a depth of 3 feet: Sand Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam n i <br /> Hardpan Adobe Fill Material . if es, e <br /> p D � - � <br /> i <br /> jPlot- plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: lNo septic tank or seepage{pit permitted i# public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT IJ /4 1 <br /> ( } SEPTIC TANK[ } J Size9�. _ �l,I W..'�AU-A_.:......___ Liquid. Depth -•--•.--••--.--.... !" <br /> Capacity------------------- Type ......-----------_-- Material...................... No. Compartments ------------- r <br /> Distanceto nearest. Well -•--•------------------._.---...----Foundation _______._....... ----- Prop. Line ................,.....6 <br /> LEACHING LINE <br /> [ ] No. of Lines ___________________r_,. Length of each line............................. Total Length <br /> D' Box ..-......... Type Filter Material ....................Depth Filter Material. ............................................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ...... a <br /> SEEPAGE PIT O Depth ._-...........---•--- Diameter ........... Number ............................ Rock Filled Yes ❑ No 0 , <br /> Water Table Depth -----------• .........................Rock Size ................................ <br /> Distance to nearest: Well ----------------------------------------Foundation -------.__.......... Prop. Line - ................... <br /> REPAIR/ADt1ITION(Prev. Sanitation Permit�'-`.....:----------------------................... Date .............................. I <br /> Septic Tank (Specify Requirements) ................................`.._......--....--. ................................. <br /> Disposal Field (Specify Requirements) -----p'Z.<�7�..s. »----- ----------- --------- ------------------------------ i <br /> ------------------------- •---- --- --------------------------------•-•...--•----------------------- <br /> -_------•-----------------------•---------•--------------..--.- --------_---.----------------- -------•-•--.....••--•-•--------•--•----•----- ..._.. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that .fhe 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. 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 empliay any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> d <br /> i <br /> Signed . -----•----- ............................ Owner � <br /> $Y - <br /> _._ .. - - - --------------•---_------------------..-•------._ Tit e ------------.........................--.... --•------------------------- <br /> ` (if other than owner) <br /> - OR .D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �� r ---•--------•-----•-------------••---._...- '----------- DATE ..� ,, ._...-- <br /> 8LIILDINGPERMIT ISSLIED ------------------------ _-----------------------------------..--_._-.--- -------DATE ...----... ................................ <br /> ADDITIONALCOMMENTS --------- ----.._.:--- -`--•--•----------------- ----------•--•-------------------------------- ...... --------..­-----------............ ............... <br /> --------------------- -------- <br /> ------ --------------- ---------•-------..-....... <br /> /a------------------------------------------• ..--•---.._....--------- <br /> (_ <br /> Final.Inspe_iion : __. ` __ ,/ -._.................. <br /> .........................Date..�'1I, ---------- <br /> EH 13 J am, `; SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />