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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ............ ........ .._.--••---•-••- Permit No: 75�`�yT <br /> (Complete in Triplicate) ..:.................. <br /> 1 <br /> r <br /> F = -. <br /> s Date Issued Z-.:1..3 ;7 S <br /> ......................•.............._.................... This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Sa Jooquin•Lacal Health District fo� permit to construct and install the work herein <br /> M <br /> described. This application is made,incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> X Y � <br /> JOB ADDRESS/LOCATION., 4Z. .. '; -: ... - .....:.: CENSUS-TRACT ........................ <br /> ... <br /> Owner's Name .. ....... ..._ ...........:............ ........Phone ... ......... <br /> kitY <br /> Address ------------------------ -....1. .(1.. ............. <br /> . ..... . . .. _.�__S� C ----•- - -- ... - - ---.............. - - --.....-- <br /> Contractor's Name ......A.......-_.:. ---- ._ � D�41'/�.::....---.License # tt7SYd ... Phone 4••----••--• ••. -. <br /> Installation will serve: Residence a kportinent House(] Commercial❑Troller Court fl <br /> .� <br /> t . Motel C]Other ............................................ , <br /> Number of living units:....... : Numberiobbedrooms=! -- Garbage-Grinder—:.._.... Lot Size <br /> Water Supply: Public System and name t.......................................................•-Cl.... .................:. ............ .....Private <br /> i= Character of soil to a depth of 3.feet:�Sand JB—Silt❑ Clay ❑ Peat Sand Loam Claf Loam <br /> tiara pa$ Adoios :. s -tY .................. <br /> �, 411I Material— If ye pe <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be-'p'laced on reverse side.)_ <br /> NEW INSTALLATION:. 'a(Nwseptic,i#dnk or seepage pit pemitte <br /> rd If-public sewer is avoilabl w thin 200 feet;) r <br /> PACKAGE TREATMENT[:]...,SEi�TIC.TANKQ S'xe` '` �X `-- �- `�Liquid Depth <br /> ----- _......... <br /> Capacity <br /> - �---...-- Type •- ----- - ------- Materiat__< .: No: Compartments ......................an <br /> Distance`to'knearest: Well .._..._.a- _._.- ........ ... ..... Prop. Line . ..: '.:,...... <br /> i� V �� e <br /> LEACHING LINE No of4line -�-�--...__._._. Length�of each line._._....:. ...._...-•.... Total Length ...Lz,Q..e........... <br /> I !!rT pe Filter Material ...___Depth Filter Material _. g._ ........................... <br /> k u ' Foundation/1 r�- <br /> Distance-to,nearest: Well...... _- ---f'...-_. Property Line ... ... _ . <br /> i SEEPAGE PIT Depth ...... Diameter ._Y8...... <br /> Numberv__--_-_-- Rock Filled Yes No ❑ <br /> Water Table Depth4................................................. k Size . �rr t._ -.... <br /> • -• - rDQ <br /> % <br /> Distance to nearest: Well ......:.. .................... ........Foundation ....1�...._._... Prop Line . <br /> k .REPAIR/ADDITION(Prey. Sanita'tion Permit�# <br /> .,,� .......................... ---------- Date ..................................) <br /> SepticTank (Specify Requirements) ....-.............. ...................................................... .......,.-----•--......._.... -'---•----.._...........-- <br /> Disposal Field {Specify Requirements} .............- ............. � ----•---•---------. .... ...................... . <br /> ----------------' .......- .- ------.....------...--------•-•- ....................... <br /> .......................................................I--------- .... - ------------••-••---.. -......... � <br /> --(Dr6" iPing:and required addition on reverse s[de)� <br /> " I hereby certify that I hay prepared this applicrt€on and that the work will be done in accardance with San Joaquin <br /> County Ordinances, State Laws�and,.Riilo.s.tc4d�Regulations of the San Joaquin Local Health District. Horne owner or licen. <br /> sed agents signature certifies the foll wing:"Y `-+ ' <br /> "I certify that in the performance otthe 4vork for which this permit is issued, 1 shall not employ any person In sueh manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ............ ... - .......• --------•---- -- - ... -----•---- ............ Owner <br /> BYi1W <br /> •----•--------------------- xitle ...._.. ............ ...... <br /> ....................... <br /> _.__. k <br /> (Ifo er t owner, <br /> r FOR.DEPARTMENT-USEONLY <br /> APPLICATION ACCEPTE BY ..........G . - -• ___.___.... DATE ._ /.. ..I . •_7�f <br /> BUILDING PERMIT ISSUED . __ ................................. <br /> .................. DATE <br /> ADDITIONAL COMMENTS � .....J . /LC - `.....................................••••-------...._............._....-•--•=—-..................... <br /> ......................... ........................... .:..� .........__._.:.R:. _i . .•--.. : .:. ........--••--.....-----••......... ........•........ <br /> ....................................•-•---.............. ............_.......__..................... ............_.....................-............................... <br /> . <br /> I ....... ..... ..... .................... ... . .. . <br /> FinalInspection by: .............. .-...............................'.............._..................--.-...._..................Date ._... ...� .._ . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> 14-13 24,i_-.-a �. y <br />