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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........ ............... Permit No. ....� <br /> f7 <br /> .................................................... <br /> (Complete in Triplicate).-...,-._ <br /> :...................................................... This Permit Expires i Year From Date Issued <br /> DateIssued ..-7:. ". 73 <br /> Application is hereby made to the San Joaquin Local Health District1Jfor a permit to construct and install the work herein j <br /> described. This application is made in compliance with County Ordinance No 549 and existing Rules and Regulations:' <br /> r <br /> JOB ADDRESS/LOCATION .......•----•--�'-.._�P.-•�-=---1N..j..�:��..............----------...e..............CENSUS TRACT ........ ........ <br /> Owners Name 13Y.$0 1 7c 7�n�.�ronp - _ .0. - ......,.... Phone . �'. .Z......... <br /> ..-•.................. z� <br /> Address ................._..........- " -• y ' City J ` <br /> Contractor's Narrie.. "-.�f:J...�i"j ? QCSRf- ..` c —.moi iceitse#i -�'`i 3`>G :.:.� ..:.. <br /> Phone <br /> Installation-will serve: Residence 016partment House f] Commercial OTrailer Court 0 F <br /> Motel ❑Other --•- ....................................... <br /> I <br /> Number of living units:.------- ... Number of bedrooms ....3....Garbage Grinder ............ Lot Size { <br /> Water Supply: Public System and name .................a^ __ -• ...... ... ........_.--••-=:---------_ ...............................Private 2q <br /> Character of soil to a depth of 3 feet.. Sand Z1 Silt❑ Clay Peat[] Sandy Loam ❑ Cloy Loam 0 <br /> (Plot plan, showing size of lot;�location of. system in xeliition to wails, buildings, etc. must be placed on reverse side.) <br /> • NEW INSTALLATION: (No septic tank or seepage pit perrr�itted_if public.sewe`r is available within 200 feet,] <br /> PACKAGE TREATMENT <br /> 'SEPTIC TANK f � '� Size------•---•-------------------• -- .......... Liquid Depth ------- ..................W <br /> Capacity -Type" Material.................. Na. Compartments <br /> r <br /> ( Distance to nearest: Well .._..._...........•.................Foundation ........._ ........... Prop. Line ....... ...... d <br /> LEACHING LINE-, ` j ] No. of Lines , -------------- Length of each line--.--_------------.-.-_-- Total Length ...._... ................ <br /> fn <br /> ........... Type Filter'Material ____________________Depth Filter Material ............................................. f <br /> r�4 I)is ante Jto nearest: Well .-1--------- ----------- Foundation ........................ Property Line ................I....... <br /> SEEPAGE PIT [_] Water Table Depth.,_._...- 'er ............:... Number ------------------ .... Rock Filled Yes ❑ No Q ? <br /> _ _ ---___--- .�... Diameter <br /> .. _ .. .. -----------I -------•-----•--------Rock Size ........----••----- •---- v+ <br /> IDistance to nearest: Well ----------------------------------------Foundation _.._...._..'-:.- ,,Prop. Line ................----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) /C;S, - <br /> .............................................-----------r--------....-:...-•---••-•------------•....-...... -•.........�..... .....------....:. <br /> Disposal Field (Specify Requirements) ....... .. ._._d.��_ - —33" i <br /> ------- ..'. ...... <br /> ...........................---------------------------------------- ••--•------------------------•--------•-- -•----•-•---------- <br /> t (Draw existing and required addition on reverse side] <br /> t <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 the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "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's Compensation laws of California." <br /> Signed ........ ................. ................... Owner <br /> By Title ` <br /> .. ....------• ............ .......... ....... . <br /> (if other than owner) <br /> 4 <br /> ' d <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .- ••-- . . •---••--•-•....................•-......------••---- ............................. DATE <br /> BUILDING PERMIT ISSUED ...........•........................ <br /> ------••----------------:.----•-...................................... <br /> --............--•-•--- --•-•-•...DATE ..................._......... ............. <br /> ' <br /> ADDITIONAL COMMENTS .............................................................•--.....................• .. -. <br /> ------------ <br /> --•---••................................................ ...:............ <br /> ...........................• <br /> -------- -------- -------- - ................................ Q ^� <br /> ............................................ <br /> Final Inspection by: 4•�..R ....•......Date /.. zz. <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> L3 2 .N h . ' . ' , <br /> f 7172 3 m ' <br />