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FOR OFFICE USE:d <br /> APPLICATION FOR SANITATION PERMIT <br /> ns' r -.�... a; _ .. �. T Permit No. - ----- <br /> '�' ECosrriplete•n-'Tripl'rcatel <br /> �. <br /> ------------------------------------------ <br /> 1"- �.. �1- Date Issued 1-�-9=---.ThisPermit Expires,1 iYear From Date Issued <br /> -------------------------------- / <br /> Application is hereby made to,the San Joaquin Local Healtli 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 /> t - CENSUS TRACT --------------------------- <br /> JOB ADDRESS/LOCATION ___-- N— �' ' <br /> AA' w <br /> - ----Phone V--- 777! <br /> Owner's Name -------- ------------------------------ <br /> si.. ------------- ------------------------ <br /> Address -------------------- r------ -__ .::_ City , <br /> --- -- * � � . yid-r 1�7 <br /> Contractor's Name ._.__-___. -- _______.Lice nse,#��.-�1�----- Phone <br /> Installation will serve: •Reside ce.XApartment House F1 Commercial :❑Trailer Court i❑ <br /> Motel.❑.Other ----------------------- --------------------- <br /> Number of living units:.__-2!�- Number of bedrooms --- -----Garbage Grinder .__ ____ Lot Size ­.;P4?_ f ___X--- -------------- <br /> '' ." ,.3 -_---------- Private ❑ <br /> Water Supply: Public System and name --------------_-;------------------------------;;-4 <br /> Character of soil to a depth of 3 feet: Sand'(] Silt❑ Clay ❑ Peat ❑ Sandy Loam Q Clay Loam <br /> Hardpan ❑-•. Adobe Fill Mdterial------------- If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system. inxrelation-to-_wells, buildings,_,etc. must be placed on reverse side.) p , <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ I Size------_----------------------------#----------- Liquid Depth -----------.-------------- <br /> Capacity ----- -------------- <br /> ---------••--Ca acit Type' _J------------------ Materials`"__-------------`--- No. Compartments ----------. ------•--- <br /> Distance to nearest: 'Well -------------------------------------Foundation --------------- ------ Prop. Line --------------------- <br /> LEACHING LINE [ ] No. -of Lines ---------------------}- Length of each line---------------_---'-------- Total Length :--------------------------- <br /> -'' --Depth Filter Material _--_______-_ <br /> 'D-Box -,---------- Type Filter'.Mati?ria! ' <br /> t `LFoundation -----------*----- -_- Property Line <br /> Distancehto nearest: Well ------------------------ --------'-"-------•-•--• <br /> SEEPAGE PIT [ ] Depth[ -------------- ----- Diameter ---------------- Number ----------- <br /> ---------I_--------------- Rock filled No y+F]j <br /> "r -.-r a- lwir <br /> Wa.ter Table Depth -------------------------------'---------•-----Rock Size ---------------------------•---- <br /> Distance to nearest: Well ------------------------ ------------ Foundation -------------------- Prop. Line --------------- ------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --_----•------------------ <br /> ------------------ Date ------------------------------•- 1 <br /> Septic Tank (Specify Requirements) ,-.-- -------=-- -.- F I ---------...----------------:------------- <br /> � <br /> Disposal Field (Specify Requirements] Lf'----- ------- --- <br /> - ------- -----e---��-1r--L--x <br /> --- ' --------------------------I------------------------- <br /> " --------------------F---='-----------------:--------------"--------------------------------------------------------- <br /> (Draw existing and required additionon-reverse side) <br /> I hereby certify that have -and-thar the workt�w'sll` be done in accordance with San Joaquin <br /> JF <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 /> K "1 certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner .r <br /> as to become subject to Workmants Compensation laws of California." <br /> Signed --------------- --------- ------ - <br /> ---- Owner �. <br /> --------------- <br /> BY --------------- -- -- ------ = <br /> ------------------------------------ Title - -------------- --------------------------------------------------- <br /> (If o er n owner) <br /> ' � EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED_BY------- ----- - -------------------------------------------------- DATE <br /> - -- --- - - - <br /> BUILDING PERMIT ISSUED --------- ---- - - ------ - DATE ------------------------------- <br /> ADDITIONALCOMMENTS ----- -------------------------------------------------------------------------------------•----=--------------------------- <br /> r/ f --------------------------------------------------------------------------------- -^_-___ <br /> " -� -- , <br /> _ <br /> - <br /> ____________________..____________________ _ _ ----- _ _ ______-_____.-___...------______---_---___.____-__..-_---___.__-__.__.__-----__.__---_------------------------------------------------ <br /> ` Final Inspection by; - - - <br /> Date --- 2��= <br /> S'AN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />