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k <br /> FOR OFFICE USE: t <br /> APPLICATION FOR SANITATION PERMIT 7� 3 <br /> ------------------=--------- Permit No. :.. .... <br /> ------------------ <br /> {Complete in Triplicate) <br /> ---------____------__--------------------_--------------- [` This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made td t1�e San Joaquin Qcdi Healt is?ri'ct ora permit to construct and install the work herein Y <br /> described. This application is made in c mpliance It C nt 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ----. -- ------------------------------ } ----CE SUS TRACT ------�_ 3^ <br /> "JPhone ------------------------------------ <br /> Owner's Name -------- - <br /> Address" -� -----xla �-- -------------------------- Cit �r `6roxrr-------------------------------------------- <br /> Contractor's Name ------------------------------------------License # �. - _ Phone <br /> Installation will serve. ResidenceApartment House[] Commercial [Trailer Court <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:--- Number of bedrooms ___---Garbage Grinder/y�__ Lot Size -` xl--,r ___ -------- <br /> Supply: Public System and name - IV--o------ ---------_---- ---_-------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silto Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam :❑ <br /> Hardpan ❑ Adobe% Fill Material ------------ If yes, type ----------------------- --- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,�gtc must be placed on reverse .side.) <br /> � , i . . y ..__...,,.—_.....�._..�� Vit. � ,..._ <br /> NEW INSTALLATION;-'�(No'--septic fi&nk or-of pit perm itted-if`public sewer �s ava Idble within-200-feetJ <br /> PACKAGE TREATMENT f ] , SEPTIC TANK ��� � _ __ <br /> y Size. _t ______________ _ __ Liquid Depth 'jam._.-____.--_______ <br /> TypW� _ .. Material- No. Compartments -:Z--t--........:.... <br /> Distance o�nearest: Well ;` `� -------_-_____-____:Foundation ;� - -fir"_"_ Prop. Line ...:........ <br /> LEACHING LINE No. of Lines _ _4-___________ 'Length of each line._ _------------ Total Length A? ------------ <br /> e r b. <br /> 'D' BoDepth Filter Material� ----------- _ _ ________________ <br /> Distance to nearest: Well,:_------------------------ Foundation /- --- ------------- Property Line. __; ............. <br /> SEEPAGE PIT [ ] DIl <br /> epths- ---------- Diameter/Ae .__.J�...___ _______ Rock Filled ' Ye's � No C] F <br /> Water Table Depth =:. r i � ------------------------Rock Size A ��=i- -� <br /> Distance to nearest: Well ____ _______________�-:_F:oundation 0-V------ Prop. Line .. ®-i.......... <br /> REPAIR/ADDITION,,(Prev. Sanitation Permit# --------------_----------------------------- Date.------------- ______.. ;. _____-- <br /> t <br /> Septic Tank (Specify Require$ents) *- <br /> --------------- -----------------------•--- <br /> Disposal Field (Specify Requirements) -----------------------------------------------------3--------------- t------------�,.,»�,--�� �---• --------- ---- <br /> ------------------------ -- <br /> r- ------------------------ <br /> ----------------- <br /> -------------- <br /> ----•----;------------------- ------ ------I------- ------ ------ ------ -------- -- -------------------- -------- -------- ------------------------ --- -- - --- <br /> (Draw existing and required addition on reverse side) l I Id <br /> hereby certify that I have prepared this application and that the workiwill-be.-done in accordance- with'San Joaquin . <br /> County Ordinances, State Laws, and Rules and Reguldtions of the San Joaquin Local Health District..Home owner or licen- <br /> sed agents signature certifies the following: 1 �� <br /> "I certify that in the performance of the work for whick 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." j <br /> Signe . Owner <br /> :f- <br /> s <br /> BY ------ Title ----- ------ <br /> -------------------------------- <br /> (If o t an owner) <br /> ! FOR DEPARTMENT USE ONLY <br /> k . <br /> APPE{CATION ACCEPTED BY -- XP.� --- -- -- ---------- ------ ------------------------- ------------` ..'....`"DATE ---- - ----^ l-7 <br /> BUILDINGPERMIT ISSUED ------------------------------------------------- -------------------------------------- ; A----------------------D---A--TE ----------------------------------- <br /> ADD1TIONAL COMMENTS ------------------------------- r'` r <br /> ------------------ ,. I <br /> ------- ----------------------------------- <br /> -----------------------------------------------=-------------------------------------------------------------------------- <br /> 3 • <br /> _________________________________________________r ____________________-____________________________________-_________.I------o-------_- _ _---------------------------------______.._________-___-__________ <br /> Final Inspection by: . Date ----- _ —��---------- <br /> f/(f ---------- V _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> kk <br /> E. H. 9 11"68 Rev. 5M <br />