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F6R OFFICE USE: , <br /> 4 APPLICATION FOR SANITATION PERMIT <br /> - 'Permit No: <br /> ,,r^,(Complete in Triplicate) <br /> ---._.- --------------------------yr:�C_ +ss—,.w.e.e+w..�n..r-�r...,gy+a�w.{ <br /> w t,�. Date Issued -- _-2-7-: I <br /> ---_,___-i .:_-_ ' This Permit Expires 1 Year From Date Issued <br /> �... f - <br /> Application is"hereby-ffiade to the San Joaquin L caPHealth District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONS ' °� ' ! 2-�--- ----- ------------------------ CENSUS TRACT -------------------------- <br /> Owner s. Name ¢-- ` --------------------------- -------- ----------- ------- -------Phone <br /> ------- -- --- - -- - - -- --- ------- <br /> Address ---------- - City --------- <br /> Contractor's Name _ -- --,•-- - - ---- r-----.License # __a�y�Z�--- Phone - �' -`-jj.�v <br /> Installation will server Residence 2�<Qrtment House,❑ Commercial ❑Trailer Court l❑ <br /> -� Motel F] Other -------------------------------------------- <br /> Number of hvin9 '�1 units - - ---- Number of bedrooms -/49--Garbage Grinder ------------ Lot Size _ - --------------- <br /> Water Supply: Public System and name --------------- -------------------------------------Private <br /> i <br /> Character of soil to a depth of.3 feet:, .-Sand'❑., ,.-Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------ 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT�[j�]. .SEPTIC TANK f ]..r Size------------------------------------------------ Liquid Depth -------------------------- <br /> ` Capacity -------------------- Type -------------------- Material---------------------- No. Compartments <br /> r„ Di�stMance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ----------_-.------- v <br /> LEACHING LINE [ J `^No:'of Lines ----------- Length of each line------ --------------------- Total Length -------__-._._._-___-_----- <br /> k- t 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------. 1-------- <br /> t Distance to nearest: Well------------------------ Foundation ------------------------ Property Line. ------------------....-- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ Noll <br /> a Water Table Depth ------- ------ -- Rock Size <br /> Distance to nearest: Well --------------------- -Foundation --------------- ---- Prop. Line --_--_..._-_-_- <br /> REPAIR/ADDITION(Prev.,Sanitation Permit#---- --------------------------- ---------------------------•- ) <br /> ----------- <br /> Septic Tank (Specify e�uirements} ----------_-------- --- --- ------ - ------------ ate-- ----- ------ <br /> Disposal Field (Specify Requirements) --! ----- ---- -- -- --V-- - ---- <br /> a <br /> Z"oV <br /> � raw existin and required ---------------------------------------------------------------------------------------- <br /> �{� ' g q 5 dition on reverse side) <br /> I hereby certify that.,l 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. Scn 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 su jecito,W km9fs Compens laws of California." <br /> Signed _--.-�- .- - �_`� - _-----__ Owner <br /> ! BY = I t� ` � Title <br /> ------------------------------------------------ ---- <br /> (If otherithcn owner) <br /> =M �.. <br /> "DEENT USE ONLY <br /> APPLICATION ACCEPTED:BY -._--_--_ - -___. DATE ___ `�x_`_- <br /> BUILDING PERMIT ISSUED ,-__ ------------------------------------------DATE -------------------- <br /> - - --- ---- -- -- - ----------- ------- ----------------------------------- ----- <br /> AD ITIONAL OMAAENTS ------------------------------------------- -------------------------------•---------------- <br /> t F e <br /> _-2777 --- ' --- ---- -- --- ---------- -- = <br /> ---------------------- ----- ----- --- <br /> - ----------- -- - - ------------------------------------------------------------------------------------------------------- <br /> rIL-p y -------------------------------------------------------------------------------------=------ -----------;------- <br /> Final Inspection—b : -� --M ` ---------------------------- Dote _ .�,, - <br /> 1 - 'I' N'••J AQUIN LOCAL HEALTH DISTRICT <br /> y E. H. 9 1-'6$ Rev. M <br />