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- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ...........................................•.----- ----- � Permit No. ......_._.. <br /> (Complete in Triplicate) ......•••• <br /> -•.. ......................... ......................... <br /> .......................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued .L�".a�.7� <br /> I <br /> Application is hereby made to the San Joaquin Local Health 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 /> JOB ADDRESS/LOCA {...{ '�� ��._ _ZZ __•tit _... <br /> ..7�. : . .....- .......-.........CENSUS TRACT .......................:.. <br /> Owner's Name ...... .................. -.__ . t��t` - ...-------•--...._:•-.-.{- <br /> Address .................. . <br /> �� <br /> --- Cr -• .... .._ ...... ......-+ r <br /> Contractor's Nome License s .. 33 `4`�/�/./._..... <br /> .. <br /> -- --- --- ----- -------��-•---�- ---.._. . ..-- -•- ---- -. ��...- ---..._ PhoneQ4- _ <br /> Installation will serve: Residen ceXApart ment-House f3sCommercial-❑Trailer Court,w;❑�--�'�- - 1 <br /> Motel ❑Other ------------ <br /> •---- •--•---- <br /> r r <br /> Number of living un <br /> its:..._._., Number-of-bedrooms,'_-3__... Garbage Grinder. ...y: ,= otSixe .._.` ,x-. ..:�....•......... <br /> Water Supply: Public System and name ...._.....__.:.. -----•--------------------------._.....44ZI -e.,-. -_ 'r --.Private ❑ <br /> 1 r �+ .K 1 `I _. - � -�3 <br /> Character of soil to a depth of 3 feet: Sand'(] 5ilt❑ Clay ❑ Peat,❑ .Sondy„L-oam ❑ Clay Loam ❑ <br /> Hardppn tL±( AdobeJ% Fill Material _... :_.. If yes, type ............................ 4 <br /> (Plot plan, showing size of lot, lavation of system: in.'relationAd w Ils, 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,) V <br /> PACKAGE TREATMENT ( J SEP Ili CTA 4 "- - <br /> SI <br /> l\liC� ] <br /> Size---------------- .!.......... ---- Liquid Depth ........................?. <br /> Capac#y ..' Type al I ._ No. Compartments r _ ... <br /> .............. <br /> Materi <br /> Distance to nearest: Well :. ................... Lundati6?�ti_.:`.' -- Prop rae -:---•-----.-.--`- <br /> 1 + v <br /> ' JJ t <br /> LEACHING LINE No. of Lines _ _ • <br /> � o <br /> [ ] - __.-. Length o€ each line_ ;.........---:.--._..:...-Total Length ........................... <br /> D,xdx . Type Filter'Material -------_ -:_:.- `th '' "mate al"' <br /> _ Dept Fi ter _.... .'._-�:.--��=�.:..._...._ <br /> stanCe to+nearest: .Well ----•----------=----- - Foundation ;--.--..:---.. Property Line _. <br /> . } . '. <br /> SEEPAGE PIT t _ Numb <br /> ( } 4'ljeLpth t ---: Diameter ..___.'--__ er `'ti _ Rock Filled Yes o <br /> li ; <br /> Water Table Depth' --------------- ---- -- --------------Rok Size ..:_._ _:...... ........ <br /> Distance to nearest Welh�«; .- ,-•.........._.Foundation_-----_. rop�-Lhne==_..: <br /> � �. . _ :._ <br /> REPAIR/ADDITION(Prev. Sanitation I.PernAtt# --- .. .. : ............. .Date _ ._..--------------------} F <br /> Septic Tank ($pecify Requirements) f <br /> Disposal Field (Specify Requirements} .d..rw " ...... <br /> ZI 11Vv Z}� <br /> --- <br /> •---- ....-- --- "............... .......• -- --•---....... '� ....................----•-.............. <br /> 1- ' ` . ------ ---------- --- <br /> (Draw existing and„regvirea..addition on reverse side) j <br /> I hereby certify that I have prepared this application and that the work will be done in accodance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San,Joaquin Local Health'Distrct. Home owner or liven• <br /> sed agents signature certifies the following: <br /> "I certify that in the,performance of the work for which thijs petL;fi�a issued, i shall not employ a y parson in such manner <br /> as to became subject to Workman's]Compensation Iaw�J of Galifbrnia." <br /> Signed .:.. .......... . . . .... -- ------ --------- ---- . Owner <br /> , <br /> By . ... . . ....... _:title--�. <br /> ----.-._ . r <br /> (If of er n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... _.. ........ DATE .... ..r...��� <br /> ' BUILDING PERMIT ISSUED ............. ................. --------- :... ..............DATE .............. �........... <br /> ADDITIONAL COMMENTS ............. -•--- ....... ..... - ..............:............... <br /> = <br /> .......... ..............................._ ----- ---------- • . ---... ------ .......... - -------...................... .................. <br /> -_-- - .__ - ---'.. <br /> ...--_.. ----- _ <br /> ----------------• •-•-------..... . ...... . . .. .._. .._ _ <br /> Final Inspection by: ...... ......... . ..... --------- - � ' � U 1. :.. .✓ . <br /> Date ... . _ ._... <br /> J <br /> . - _ ,SA JOAQUIN LOCAL HEALTH .DISTRICT , <br /> F_ H_ 13 241:.A,A Qo.. gsa 7171 1 K <br />