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FOR�CE USE: <br /> APPLICATIION FOR SANITATION PERMIT � � 7s 3 <br /> .................................. Permit Ne. ........_.. --- <br /> . . <br /> . Y (Completo in Triplicate] _ . _.� w .... . ~ <br /> '` <br /> -a <br /> Dote Issued .- ..•---_-----• , <br /> :. .....................:............. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Lbeal 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 /> JOB ADDRESS/LOCATION Z---. ........................................CENSUS TRACT ..............I........... <br /> �... <br /> Owner's Name ...... .......a-L------ - ..._._.....__._........ ......r•---...........:....:..... Phone ....._..................b-.... <br /> � <br /> - <br /> Address .............. �-...... ... ....:City .... <br /> Contractor's NameiL4 ..... <br /> .....:. '4.......- License # ._3 .3... Phone ... .. <br /> Installation will serve: Residence tf Apartment:House 0 Commercial ElTrailer Court 0 <br /> Motel 0 Other <br /> Number of living units:..... ----- Number of bedrooms Garbage Grinder ...... lot Size ..... ................ <br /> Water Supply: Public System and name -- ............. .Private,�j: <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ❑ Peat j'Q Sandy Loom 0 Clay Loam 0 <br /> . Hardpan 0 Adobe Fill M6terlal <br /> ............If yes,type....... .. ... ............ <br /> (Plot plan, showing size'ot iotl 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,] <br /> PACKAGE TREATMENT j ] SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth ............................ <br /> Calwccity ------- ---------•- Type •----•-------•:_.... Material..-----_-----_---- No. Compartments .--._..._•--•---- -- <br /> F <br /> Distance 'to nearest: Well ....................................Foundation ...................... Prop. Line ................._...� <br />+ r . - + p+' 'r-+C-4V1 <br /> LEACHING LINE [ ] No. sof Lines .......... =Length of each line-.- _-_.._ Total Length .b <br /> U-Box _.__... .... Type Filter Material ....................Depth Filter Material ........................... <br /> Distance to nearest: Well•..!.................. Foundation Property Line •.-..................... <br /> � �i . <br /> 00 <br /> SEEPAGE Pili ( ) ...-Deptt��=_�__.�- .._.... Diameter ------- ------- Number --------------" Rack Filled Yes Q"-� No <br /> Water Table Depth. - i---•..... ........•----------Rock Size ......_.... <br /> . - F <br /> Distance to nearest: Well __....t.-_.. ...L-----------------Foundation �- -_:?CProp. Line ...................... <br /> Ddte�._ <br /> � REPAIR/ADplTION(Prev. Sanitation Permit# ��---.--�_.- _.....---•--•--•:......� .. --.) <br /> Septic Tan (Specify_Requlre eats] -• . ••---.� ......... .---------•-------•.....--•................. .-------- ...... .... .011.Qisposal;' Field (Specify Requirements --�- ---- -- ••--- -----•- ---•- ---- ---••----------------------------•---•--•---••-._._...._.. <br /> --------------------------------------- .. ". _._.. <br /> .,o _________ — .. .. ............... ........ <br /> 1. (Draw existing and required addition on reverle�sidej .. ' <br /> ' 1 hereby certify that I have prepared this application and that thework will be done In accordance with San Joaquin . <br /> County Ordinances, State Laws, and Rules and Regulations.of the,San..taaquikLecal HealWDistrlct. Home owner or 11 en- <br /> ted agents signaturectifies the following: ` "` , <br /> "I certify that in the performance of the work for which'this permit is issued, 1 shall not eMploy.any person in such manner <br /> as to become subject to Workman's Compensation laws of California." 3 <br /> rSigned -------- - ------• -- ---•----- .. . ...........- .......................... Owner <br /> By _..._.__,. .. =.._.* ..--......_ •-----•-•--•-- ----•-•--•-•--- Title <br /> -----------------------•-----•••-_---........ <br /> (I at than owner) <br /> FoW00ARTMENT USE ONLY <br /> APPLICATION ACCE TED B ° - t'f =-•--------- ---- --. DATE .... ` ._.a i.>"..,...... <br /> BUILDING PERMIT ISSUED .... - .............................. ... r' DATE -..,._.-_ <br /> ADDITIONAL COMMENTS - / L ------ <br /> �.:.:. ...�i.. <br /> t <br /> ........_. <br /> ' ----•-----------------------•----------•- <br /> -•- ---------•--------••----------- -- --- e- �'-•4'"~-----"--•--" ---•----•------"' ------------------ <br /> ---.. ..--------- <br /> -- ---.. -•-----• +1y� <br /> e - 1- e <br /> Fina! Inspection by: � ' "�4 '= `-----------.Y..--- •-----•--•------------Date 3 <br /> .4 <br /> �� 2 �'b 1 5M SANYJOAQUIN LOCAL HEALTH DISTRICT 87]1 3 <br />