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FOR OFFICE USEA <br /> P . ' <br /> APPLICATION FOR'" <br /> t3SANITATION PERMIT cf <br /> - - n - -*- - Permit.No:, <br /> •• <br /> -�--�-- � (Complete in Tri nate <br /> �,,,�J P P <br /> I -------------- <br /> l.�'" i hate Issued 5 - 7�iThis Permit Expires 1 Year From Date Issued <br /> f ------- s <br /> i <br /> Application is herebym to quin Local Health District for a permit to construct and lestalk the work herein <br /> described. This app) odr4compliance with County Ordinanc No. 549 and existing Rules and Regulations: <br /> A <br /> 108 ADDRESSfLOCATPff <br /> _--_�- --- ---- = CENSUS TRACT --------------------- --- - ------------------- -------PhoneOwner's Name. -.= --------- -------- ec.. �. 'Y------------------ <br /> City _.cam" -----------•------- <br /> Address - -L'� ------ . <br /> - ----- :. <br /> wd,,t .� --- <br /> License--------------------- <br /> ----- Phone <br /> Phone _ <br /> Contractor's Name --== - Residence A artment House❑ Comm:er ial : ' <br /> . id(' ❑Trailer Court i❑ <br /> Installation will serve:. 4bl p <br /> � r <br /> Garba--e--Gtinde- ry F <br /> Motel ❑Other;,.-'------------------------------------------ <br /> Number <br /> ---- --------------- -- {#t <br /> of Size - <br /> Number of living units:-_-- -.--- Number of. bedrooms _____.___--_ g , , ; - -�--- <br /> ..� y r---------------- <br /> . <br /> -- ^-- ---- r- � Private <br /> ' E]- <br /> ofPeat <br /> Water Supply Public System and'-name _ � �ti • ----•--- --- - --------------------""{ ----�------•----'---"'"-- <br /> ...�_ o- <br /> Character of'soil to-a depth Veet: Sand'❑ Silt❑ -Clay ❑'" Y ❑ -"�� M <br /> Hardpan ❑ Adobe ❑ Fill Mate ial <br /> ------------ if yes;type -"-- -- , <br /> (Plot plan, showing size of lot,�location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> I i <br /> NEW INSTALLATION: (No-septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> _ `, Luid, Depth-__- ' <br /> PACKAGE TREATMENT 'SEPTIC TANK'[ ] Size -------------------- ----------< Compartments <br /> No. <br /> Capacity ------- ------------ Type ---- Material--------- � <br /> = <br /> s Distance to nearest: Well ___________-_ :__-.-Foundation ---------------------- Prop. Line ____-____----:-..--..- <br /> -----�--- s <br /> t -------- -_------------- <br /> LEACHING LINE [ ] No. of Line__ __:__---,-`- ------- Length Length of each line---------------------------- Total Length __ +-- ti ... , <br /> D' Box .-__ --- --- Type Filter Material --------------- -Depth Filter Mateiiai --------------,----------------------------- <br /> V <br /> -------------------•--•—f ✓, <br /> 64, 'x 1; `�' <br /> ------ Foundation -1- --------- Property Line. <br /> ---�.�--•-^ter Dis#ante to nearest: Well ----------------- � t,:. .; _,�, - �,x <br /> t ------ Number --- - ---- ------ Rock-Fi�ledE Yes,,❑, No v <br /> SEEPAGE PIT [ ] I Depth -------------------- <br /> Diameter <br /> t Water Table Depth ......................... Rock Size = - <br /> 1Foundation <br /> REPAIR/ADDITION{Prev. Sanitation Permit�# -.----:--" --- -- <br /> -----------.Prop'Line ----4•--------------- <br /> ! Distance to nearest: Well----------------------------- ---------- <br /> ' ' --------------- ------j Date -------------------------- � <br /> i --_ � <br /> - .� <br /> Septic Tank (Specify Requirements) ---------------------- ---------- --------- ------------------ - <br /> / . <br /> Disposal Field (Specify Requirements) --------_ � --- -- <br /> ._ ----- <br /> - -------- ---- - <br /> ------------ --" (praw existing and required addition on reverse side) t <br /> I hereby certify that I have prepared this application and_that.rthetwork will be done}iii accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local'Heallh';1]IStCICt:Home owner or lieen- <br /> i sed agents signatdre certifies 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 subiect to Workman's Compensation laws of California." <br /> s <br /> Signed Owner <br /> f . <br /> _z s <br /> Gu - <br /> -------------------- <br /> .BY -----=------ - -- ---- -- - - <br /> - - ------------------- <br /> {I oth an owner) <br /> R .DEPA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED -------------- --------- --------------- DATE <br /> BUILDING PERMIT ISSUE ------------- -----DAT -------------------------- ---------------- <br /> ADDITIONAL COMMENTS ----------------------------------------------------------- <br /> ------- - ------------------- - --------_----------------------------------------------------------------------------•--------- <br /> - <br /> ----------------------------- - - - - ----- <br /> ----- ---------- - ----- <br /> Final Inspection b - --------- ---- Date <br /> SAN JOAQUIN_L•OCAL•^HEALTH DISTRICT, <br /> E. H. 9 1-'h8 Rev. 5M a .r: ,.3 <br />