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Y a <br /> `v FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT(Complete in Triplicate)......,�r!-7'..............��.Fy.rT..-t'�.-..L�.. � �* Permit. No. ?Lb. <br /> .7 <br />....................................................... <br />....................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued '��..z� <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 mode in.compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _...J._;�,R.��-._..7/. -. . _. �-� .......... .........................CENSUS TRACT ................ <br /> Owner's Name,.....__Ls. .@ 9_ i �y q ----------------- <br /> '..... -.Phone I-OV ....�... <br /> Address -----------`} ... - .- ......... City _.._...... ........................... <br /> - <br /> 4 P <br /> Contractor's Name .- ? / ._---`License # Phone ...<lfa. .:. ��f '... <br /> I stallation will�rve: Residence [ Apartment Hou a o Com ercial ❑T a ler?Court 0 I <br /> F <br /> Motel ❑Other .............. �. `.. ........ j <br /> j <br /> Number of livin Aunits:.. Number- of bedrooms __._. Garbo a Grinder ....._.. YLot Size: _0._'1_JV4.................:: <br /> Water Supply Public System and na *._ ~' ....... ..........�'{ .._..__....0.Private ❑ <br /> •--•••--.__•---- <br /> Choracter of soil to a depth of 3 feet: a S d ❑ Silt❑ Clay ❑ 'Petat❑;' andy Loam ❑ 'Gay Loam ❑ <br /> r Hardpan ❑ Adobe-0 Fill Material ............ If yes,type .... . ........ ....... <br /> (Plot plan, showing size of-,lot, locbtion of system in relation to wells, buildings, etc. 'must be placed on reverse side.' <br /> NEW INSTALLATION. INo septic tank or seepage pit permitted if public sewer !s available within 200 feet,) Ilk <br /> PACKAGE TREATMENT [ I SEPTIC TANK t ] Size_________________________________________.......................................... liquid Depth ..._......._.. ........... <br /> ' CapacityType Material______ No. Compartments <br /> Distance to nearest: Well r <br /> P� • - --......-------•--------•--Foundation ...................... Prop. Line ...................... �1 <br /> LEACHING LINE [ J No. of Lines '. .................. Length of each line.------•---------_--_---'-__ Total Length _._____ ..................... <br /> t '%'NN I <br /> 'Dj Box ........ __. Type Filter Material ....................Depth Filter Material <br /> Distance to nearest: Well ......................b_ Foundation ......................... Pfoperty Line ........................ i <br /> SEEPAGE PIT Depth _.,_. t.._ _._ Diameter hl _ ..Q,Number ...____.... . r Rock Filled Yes q6 No <br /> [ p = <br /> 1 Water Table Depth ---------------/n._A-----....................Rock Size _____ - - 1 <br /> E Distance to nearest: Well---------'"-'r" -------------Foundation ----- .- ------- Prop. Line ------ ............ <br /> i <br /> REPAIR/ DITIO `Prev. Sanitation Permit# -------------------------------------------- Date ....__--_______..:.----__-__..._:) <br /> . i <br /> --%ptic Tan.Qpecify'Requirements) -••---------------- ------------------------------------ ................................._......... ..__... .................. <br /> Disposal Field (Specify :Requirements) ..__.__. ........... .. �1 ._. .^..•-/ _______________________________________________ <br /> --------------------------------------------------------------- ------- ----------------------------------------------------------------............... <br /> -----------------------------',--------- •-•-••------* ..... -•--•-------•-----------------„ ...................... ...............--............ <br /> -.................................. <br /> -....... <br /> (Draw existing and required addition on reverse side) <br /> I.hereby certify that i have preparedithis 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 1 . <br /> as to become subject to Workman's Compensation laws of California.” <br /> i <br /> Signed --------------------------- ------ Owner <br /> Bye------ .......... .......... Title -------- ? er_ . ........................ <br /> (If other than owner). <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... _.-• • ----•...........................................:.............••------•--_.... DATE......... - �= —-------y <br /> BUIL'DING-PERM'IT"ISSUED -�-:', :.-: .. . .--_- :` ,.............................................. <br /> ADDITIONALCOMMENTS -•-•-- - - ---- -- --- - ----- ........................................................-............._.........................:......-.._............... <br /> .. <br /> ....................... ....... ......... .........................•---................. ....................................................... <br /> .......... .................... <br /> :.... ._... .... <br /> ....._......__....._._.-•--•--._..__........----_...._.__..---•-•-•-- -------• ---•----___--- ..• <br /> ..._ •............. . . <br /> Final Inspection by: . _._ ...---.....Date ...... <br /> SA OAQUIN LLOCAL HEALTH DISTRICT <br />�l <br /> ; - H, 13 24 1_�hA Rpv 5M 7/723 M <br />