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: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT , <br /> t No. -7,7:: ; 5 y <br /> ....-..._�... .................••- PermiPF (Complete in Triplicate) <br />__!.e00,-............................................. <br /> -------- ------ ------- This Permit Expires 1 Year From Date Issued Date Issued -7......._......, <br /> Application is hereby made to the Son Joaquin Local Health District -for a. per 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 /> f� li <br /> JOB ADDRESS/LOCATION ..... _ f. .`r.. . ... ................... .....:CENSUS T <br /> RACT ...�..... <br /> r a: F <br /> Owner's Name ........ ...- � _ .. , .-• -•-• Phone,............ <br /> .O.�.. <br /> -..•...........Address l City . <br /> dam' <br /> Contractor's Name '•.....-•......................'.........-•----..License # .... Phon . :....6�gf� 7...... <br /> Installation will serve: Residence KApartment House Commercial :❑Trailer Court �] it <br /> 4 . <br /> Motel ❑Other ----------- --------------------------------- . _... <br /> Number of living units:.... Number of bedr oms i_. ....Garbage Grinder ..�.__._._:_°Lot Size .. �...x-� •---........ <br /> Y -- 79 i �' = _ ..........: .....................................Private <br /> Water Supply: Public System and name .............��1-.:__._ '�-�•� = ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat Cla❑ Sandy Loam ❑ y Loam ❑ <br /> Hardpan ❑ Adobe. Fill Material ...._...____ If yes, type ....-' .. <br /> 7 _ ii <br /> (Plot plan, showing 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 seepage pit permitted if public sewer is available within 200 feet,) �� a <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ J Size-.............................................. Liquid Depth ...................... <br /> Capacity -------------------- Type .................... Material................~.....4No. Compartments. ....................... R <br /> ....... Pro Line <br /> Distance to nearest: Well ---------`":.........-•--___---....Foundation --..----•_ ........... p. ...........:.......... <br /> LEACHING LINE No. of Lines g a y - ` • g <br /> [ 3 - ------------------------ Length of each line``-----.....----:_�`....... Tota! Length ------...........:........_. <br /> 'D' Box -----------.Type_Filter Material ....................Depth Filter Material ......... °.......................... <br /> Distance to nearest: Well _....................... Foundation .................... Property Line ............ ......... <br /> SEEPAGE PIT [ ) Depth ---- ------------- Diameter ................ Number ......................... Rock Filled Yes ❑ No <br /> Water Table Depth .............Rock Size _..-............................. i; <br /> Distance to nearest: Well .. .........Foundation .. Prop. Line <br /> REPAIR/ADDITICIN(Prev. Sanitation Permit# .......................... r Date ...:____.._...................-.--1 <br /> �.......__. , <br /> .. . <br /> Septic Tank (Specify Requirements) ................. ........ � .. ._...._..:_........... ....... <br /> Disposal f=ield (Specify Requirements) -----SCK� .•- 'IA--. j -- .................---------------------= •- <br /> ------------------------.................... <br /> ...........----------------------------------------- ------------- <br /> _. ...' r <br /> _ ... • ..._. <br /> --------------- ----------------­- ------------------------- ..........-...... -..............................................................-------•...................... <br /> (Draw existing and required addition on-reverse-sidel.666- --- j, <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. Horne 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 such manner <br /> as to become subject to Workman's Compensation laws of California." it <br /> J <br /> Signed ......._- _ -L.,.�� ---�---• -----•-- ....... Owner <br /> B Title .- .- �_.- _-..................... <br /> (If other t n owner <br /> FOR DEPARTMENT USE ONLY '" a <br /> BUILDING PERMIT ISSUED ...... <br /> ....A.............................:..j :.>.:: .........--------- ------ ..........._..........DATE ......------------.APPLICATION AC PTE 8Y .. _- -----=-------------........_... - DATE ..... <br /> i <br /> ADDITIONALCOMMENTS ..............................................--.............................. •--------....----=---- ---..... ................................... <br /> ---------------------------------------- -------- .......--....-...........................................•-•---••---------------•---._........--•--......................... ......•...._.. .......... <br /> .......................:. ......_..:.... ................................................... . --..-.----------...................... ..._...._.. ......._ <br /> --------------- -- -- ---- -• --- •----•------------.....-----..........-----------...........----•---•- i <br /> Final inspection by: .............. .............• Date _. �1 ..-._._� --- <br /> ------------- <br /> V <br /> . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> w 13 241_-maod., r,AA 7/723M - <br />