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f <br /> 1 EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ...7 3 3 a <br /> :............ ..................:.. <br /> (Complete in Triplicate) <br /> (06 <br /> f "--"-."-.---..... This Permit Expires 1 Yeat From Date Issued Date Issued . `!r:........�. <br /> r <br /> I 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 /> JOB ADDRESS/LO .. ON iK.7�1.......... :........6O. ... ..........................:......CENSUS TRACT <br /> Owner's Name T:,f�:y�W . .......... ---•-•_------. Phone •-----•-- •.............. <br /> Address S C� Z City �J-•------•.......................... ....._.._................ <br /> ............... �__�_�----- ------- � <br /> i � ;- - , ,...License'# ._-—473_-YPhone ....:......... <br /> I <br /> Contractor's Name ..... 4 ' .. .f .---.. ,._ <br /> Installation will serve: Residen ❑Apartment House C mmercial❑Trailer Court 0 <br /> Motel ❑Other ------- -4.. ................. <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ._.--------- Lot Size ........................................... <br /> : <br /> lWater 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 Materiel ------------ If yes, type ............................ <br /> {Plot plan, showing size of lot, location of system in :relation to,rvells, buildings, etc. must be .placed on reverse side.}� <br /> NEW INSTALLATION: <br /> � (No septic tank or seepage pit permitted if public sewer is available within 20E)-feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size.:.......................I........................ Liquid'Depth .........•...... ......... <br /> y <br /> Capacity ....Tye® .�.^ Material .....- No. Compartments <br /> Distance to -nearest: Well ........ -? ......Foundation ...... Prop. Line <br /> LEACHING LINE [ J -"No. of Lines .........::............. Length=-of each ,line.----_----.--------_._-_--: Total Length _-__..__ ............ - <br /> `' ......... Type.Filter Material ..Depth Filter Moterral"' <br /> . .- D Box � :.......:......... � ......-----------------------......_........ <br /> Distance to nearest: Well ......f::...... .. Foundation ......................... Property•Line ...:................. <br /> SEEPAGE PIT [ Depth ..:....' _...:-:`Di meterhlumber ..................•._... Rock Filled. Yes ❑ No r❑ <br /> I <br /> -,WC-iter Table Depth ........... ......!..Rock,Size <br /> Distance to',nearest: Well,-......................... .....Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# _r...a.......................... `:•••.... Date .................................. <br /> Septic Tank (Specify Re virements) .............'---••---------------------------------...---------------------------Y------------------------_.......--•---------•------------ <br /> P I P fY q <br /> Disposal Field (S ecify Requirement`s} ----- <br /> _-______._" <br /> ... - - -------... <br /> l (Draw existing and required addition on reverse side) <br /> 1 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 the7San Joaquin Local Health District.dome owner or Rcen- <br /> sed agents signature certifies the following. <br /> t "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' mpensation laws of California." <br /> Signed ...:.------------•-----------------• -- •-•---:.... ...... -•--• ............._ Owner <br /> • r <br /> ...� . ;Title .... .........:.... <br /> (If other than o er) <br /> r FOR--DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.._ ............................................................ DATE .. _a__- ............. <br /> BUILDING PERMIT ISSUED .................. .:.....:..............DATE ....................................._..... <br /> ......................... <br /> ADDITIONAL COMMENTS -•---------------------••-----....--------•------............................................. <br /> -"................................... ....................... ......................................... . ..................................................... ................................... <br /> .......................... -•.........:......•-----------------•--------•-•--------------------------••-............•----•......... <br /> ................ .- ------------ _----- _------- `= :.. <br /> Final Inspection by= yt,�' 'a .�- _:.. • .................... Date . _._" J "._. . <br /> SAN-JOAQUIN -LOCAL HEALTH DISTRICT <br /> F u <br /> 13 24 1_,Au Q.v KA 7172 3 �K <br />