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` FOR OFFICE USE: r <br /> k ' APPLICATION FOR SANITATION PERMIT <br /> .._... ......................-...-....----•-• Permit No, ....... 7 � <br /> i (Complete in Triplicates <br /> - /Date ...�:A. <br /> I......................... p _2 .�o—3 a <br /> This Permit Ex ires i Year From Date Issued <br /> t Application is hereby made to the'San.Joaquin Local Health District for a permitlto' :construct and install the work herein <br /> described. This application is made in compliance with County Ordinanoe,No', 5d9 and• existing Rules and Regulations: <br /> JOB <br />}i ADDRrrE��SS/LO_CAT�LNs-S <br /> .... ..-- <br /> ` ;j <br /> ENS <br /> UoS <br /> TRACT � �...... <br /> ...................•-----•---:......:.............. ............. PhOwners Name .- ...Add <br /> Address ..... city --. # <br /> Contractor's Name e �._.....:_.License � ------ - . <br /> Phone .JrP�'�c <br /> Installation will serve: Residence, partment-House 0-Commercial C]Trailer Court ] r <br /> L, .. <br /> Mofel [)Othet._=.- ..............:....... _. <br /> /4C/� <br /> Number of living units:............ Number of.bedrooms .. .....Garbage Grinder ....:._...._ Lot Size _ �. _ � <br />�. System - <br /> .name <br /> � ._ <br /> - -----PrivateWater Supply, Public _and ; ,•- f. -- ..-_......: . . <br /> Character ❑�� A <br /> of sail to a depth of 3 feet: Sand H�iit❑ Clay❑ _y Peat ,Sandy Loam,fli %.Clay Loam.0___ <br /> tHardpan 0, Adobe ❑ Fill Material .!.......... If yes, type ....................... . <br /> (Plot pian, 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,) �l`' <br /> I PACKAGE TREATMENT [ ] SEPTIC TANK I } Size........._._,.•-•--_-............................ Liquid Depth ............... OI ' <br /> Capacity ................... Type ..................... Material---_---------------- No. Comportments I <br /> Distance tb nearest: Well ....................................Foundation -----------_-------_ Prop. Line ..................1 -, k <br /> LEACHING LINE [ ] No. of-Lines :....................... .Length 'of each ilrie--..................-......... Total "Length" `-........................I <br /> V Box ............. Type Filter Material .................:..Depth Filter Material ............................I............ <br /> Distance to nearest: Well ......................... "Foundation ........................ Property Line ...._,.................. <br /> SEEPAGE PIT [ ) Depth ..... .............. olameter ...----_------- Number_......:_::--:____._:_...._...-Rock Filled Yes 0' :: No C <br /> Water Table Depth --Rock Size ._. <br /> i ............ <br /> Distance to, nearest: Well........................ ..............Foundation --------.._.. ...... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation; Permit# ..........................................--,Date --------•..----....._:_ ._..._.._) <br /> , . _ <br /> Septic Tank (Specify Requirements) - ------ .............= -----•-••............. ;..•...-•---...... ............ ..................................... <br /> Disposal Field (Specify Requirements} -- (}......_ -`"..=- 1 (-t ............- ........... •�r ...r ./�. ..C.. <br /> .................. ........................ <br /> ....:. . .. ..................... ---- j -------•----. -- ................... •-- <br /> --.--........... ............................... _,. -- .,..............-.... ............................................................. ........._......... f <br /> ' (Draw existing and required addition on reverse side) <br /> I heieby 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.'Horne owner or lice�t- <br /> sed agents signature certifies the following: ., <br /> "i certify that in the performance of the�work;for which this permit is issued, 1 shall not employ any person In such mannert <br /> as to become s ct to Workman's Compensation laws of California.", .- `• t "" <br /> Signed . <br /> = ,: - = = Owner, <br /> c f �.. <br /> BY ••------- --- .. Title QC•c�!{J ...' < ,�.......... Uf��t. <br /> (If other than owner)t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION. ACCEPTED BY tri.... :. ... ........ ................ .".. ._.------..-....t.-----..... DATE .. :.- 1.: s-`..-•.-...._ <br /> ti <br />` BUILDING PERMIT .ISSUED... DATE _.:___.•--------------.=-------•- <br /> I -ADDITIONAL COMMENTS <br /> ..�.............................................................................. <br /> 1 s .• ............I.................................... r'.......---------------------------............................... ...............a.........................................• <br /> ..........................................1./ :- .� ..... ................. <br /> ..... ...............•..............-.. • ,L. !1 .-....I.....-. <br /> FiFinal inspection by: ... Vii' i -` ...... <br /> nal .............. •• . -•--...©ate '.r.... `5, .....--•-•----- <br /> ' t: SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> ..... ._. 7 <br /> f F'H_J..3 241-'-" <br /> ;*6a Ra�,.SM. � �� .31723M <br />