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FOR OFFICE USE: <br /> APPLIdkTION FOR SANITATION PERMIT .211 <br /> (Completo in Triplicate) Permit No. ..................... <br /> V <br /> ... ... ............................................... � This Permit Expires 1 Year!=rant Deft):seed Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const d and install the work heroin. <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulotkms< <br /> JOB ADDR€SSACICATION .IeF_?. ,� �2 r� <br /> ...... ........... ..... .. SI.�_._........._..._....................----..............C� TRACT .......................... <br /> Owner's Name ...... r?......._ ' ..._._Y- � jc- ! ....--•................•_--......................._...........Phone ------------- <br /> Address _ _......�..-. .... . '__..........City ... ... <br /> -------------------------------------------- <br /> Contractor's <br /> ....._..... .._...Contractor's Name '' <br /> . ,, .7.....,-.....f es......................LMen:e# ./.1!3' ��' ' Phone .................. .......... <br /> Installation will serve: Residence❑Apartment House I] Commercial❑Trailer Court ❑ <br /> Motel [I Other........ <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder ............ Lot Sin ...................................... <br /> Water Supply: Public System and name ................. ................-----............._ ....................................,.........Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Gay ❑ Peat❑ Sandy Loom G8'' day loam❑ <br /> Hardpan Q Adobe fl Fill Material ............If yes,type........................... <br /> !Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be pkmd on reverse side.{ <br /> NEW INSTALLATION% (No septic tank or seepage pit permitted If nublk sewer is available within 200 fest,) <br /> PACKAGE TREATMENT I I SEPTIC TANK f 3 Sized .� .�..-1�. S �........ Liquid Depth ...C.f---..1............. <br /> Capacity ..- Type - ' Material....: !... ... No. Campartt onft �!=............ . <br /> Distance to nearest: Well ............. �..1a...........Foundation .........../t,( ... Prop. <br /> LEACHING LINE G No. of lines ......./---------------- Length of each line....... Total Length .... �.�-T..... <br /> 'D' Box .. ---.-- Type Filter Material .....—?.� .....Depth filter Material ..../.`i............................... . <br /> Distance to nearest: Well .........S_L.,F!-. Foundation ......... Property Line ..... <br /> SEEPAGET I l Depth ...---••---- --.... Diameter ............. . Number ............................ Rods Filled Yes ❑ No <br /> Water Table Depth ................................................Rodc Size ...... ......................... t, <br /> Distance to nearest: Well .......... ...........................Foundation .................... Prop. Line ..........,........... <br /> � <br /> REPAIR/ADDITION#Prov. Sanitation Permit+#t ............................................ Date .................................. � <br /> Septic Tank (Specify Requirements) ..... ..... . .......•---.......... .............. .............:„............................................................. O <br /> Disposal Field (Specify Requirements) <br /> ---•---------------------------------------------------------------•--------•-------•---•----•--.....................--•---...---....----•----.....................-....----.............................. <br /> •...................................• -------­-­------- ------------ -------- .........................._............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that l have prepared this application and that the work wiN be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HeaW Dishict. Hesse owner or Now <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 en+pley any person in such nmmner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- ----1�... ............ Owner <br /> BY ----- -- "s`� �� . Title . ---.-_... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _..... �:: t_ -.:................................•----.........---.......... DATE --- '`/ A-".. ........... <br /> BUILDING PERMIT ISSUED _..._-- ------------ ----------------------•-----........:_-:.....-------- -- DATE .. .:._..:_...._.._...................--- <br /> ADDITIONALCOMMENTS .....................................................................................: <br /> ------------------------- ........._-.................................. ......................................... <br /> ........ .. <br /> Final Inspection b _ 41�T ' <br /> P Y ........ ...........:.........Date ... . ........ .....................2!� 1-6E3 Rev. 5I SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />