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� FOR oFfler USE: <br /> PLICATION FOR SANITATION PERMIT <br /> ............... <br /> ..........-------------•_•-....,..- Permit No. .� <br /> 25- <br /> '.' )Complete In Triplicate) <br /> ..........•.............................•.I.. .........- s�:a - 7� <br /> ................ Date issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> r <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 10 r r e.._, 12�i.�. S� Co vrnn /-a r�r. ....1?.._ .�CENSU5 TRACT .......................... <br /> �I _ <br /> l Owner's Name - ...1.�.4.0 ic.c_�-.1.-------- •.... .......................... ._.Phone '9�/Z_�1...z--- <br /> Address 1.2- l c?rr. .- -+- -:.[�77rrr. srn�.�..:1 !_.'!:._.�..............city ..._5 .. <br /> Contractor's Name License # ..........;....:::....... Phone <br /> ^- ---------------------•-•--•......................--- <br /> r Installation will serve: Residence Apartment House Commercial <br /> J <br /> � © P ❑ ❑Trailer Court <br /> ' Motel ❑Other r ' <br /> i <br /> -Number <br /> of living units:.-.--I.... Number of bedrooms .... .....Garbage Grinder ............ Lot Size ..... d.v; - -------_. <br /> Water Supply: Public System and name ................ <br /> .----------------------------------------_............_......................... ------......Pri ate . <br /> Character of soil to a depth of 3 feet: Sand Ej Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> } _ j <br /> Hardpan 0. Adobe 0 Fill Material ............ If yes,type ............... ............ <br /> l (Plot pian, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepa ,pit permitted if public'sewer is available within 204 feet,# S <br /> PACKAGE TREATMENT { SEPTIC TANK Size. �c1..,x:.. .......... Liquid Depth .--- = .-fb <br /> Capacity . -2G --- T p �t..`� � ateriat_ #r . No. Compartments <br /> Distance.to nearest: Well ...1.9 1.9L.-5.....� Foundation Prop. Line s _Vme-.. <br /> LEACHING LINE ( ] No. of Lines. ........................ Len th of°each line-.......................... Total length ............................ <br /> �D' Box -Type Type Filter Mlp'terial ......Depth .Filter Material <br /> Distance to nearest: Well ........... Foundation ...................:.... Property Line <br /> i - -. I[1IXsbr .. <br /> -Deptl """ Q::`:. -...--.•-•---.... Number .........:..f......, - Rock Filled Yes 0 No O <br /> 1:7 e,: i? 4 Water Table Depth ,x.-.13 _-- Rock Size <br /> 5-06 s' f f. . Distance to nearest: Well ........... .......... Foundation .....ze�__.... Prop. line . ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ....._..... ----------------- ------ Date ..__._................._... ...... <br /> G Septic Tank (Specify Requirements} ........ .................... ................................ ..........................I............._................. <br /> DisposalField (Specify Requirements) ..............•..............................................=-•................................... .................................. <br /> ------------------------------ ----• -••-•- -------------------- ------------............................................................................................ <br /> (Draw existing and.required 'addition on reverse side) <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home owner or licen- <br /> i sed agents signature certifies the following: <br /> "I certify th5hfperforman of the nark for which this Penn It is issued, I shall not employ any person In such manner <br /> to Work n's Cam s ion laws of California."as to bec e . <br /> Signed __ ---- Owner <br /> BY ------------------ - .-...-----.-------------•----------------- -- --••---------------------- Jiile .................. -------------------- ---------------------------- <br /> f_-,o er than owner) <br /> FO DEP TMENT Lt ONLY <br /> APPLICATION ACCEPTED BY --- - ------ - ------------ -- - -- •- --49.41- -�,�.......---- DATE_.-....,... .x <br /> BUILDINGTIOPERMIT ISSUED ---•-----•- ------ -- ----------•--........------------------------------.:--.DATE .--•--- -......--...-......-- <br /> ADDITIONALCOMMENTS -•-- -- - ----------- -----••-•------ ---------•-------------- ..... ---•-----------------------------------------•--- ............. <br /> .. . ........... ........ ...........-------.................-•--••••--•------------------------------------- ---------------------- <br /> . . ---•...- .--------......-•-----------------------•-----•--....-------- ..... <br /> - <br /> Final Inspection by, ----------- >.------ <br /> :.. Date .....-,� .. ' .. . ............ <br /> J 3 2t� 1--613 Rev. 5M SAN JO QUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />