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r <br /> ' w FOeOFFICE USE:. i' <br /> APPtJGATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. �lv. <br /> - � Date issued .7--XC.73 <br /> .............................. ................J This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct cnd install the work herein <br /> described. This application is made in compliance with CoVnty Ordinance No. 544 and existing Rules and Regulationsr <br /> JOB ADDRESSAOCATION : .....� . -.C�,h..:.. . <br /> d1 --.. ._... . ............ • ............ CENSUS TRACT .................. -••- <br /> Owner's Name ... .. ._.. .. <br /> ..........I. ........ . .. ......... .Phone ... .... .... ... ........ <br /> Address ... ...... .. ,. . City ........ ...... ......... ......... <br /> .- . ... <br /> Contractor's Name .. 4.4 . ........ .... ' -..License #a a�,f'� ._. Phone /? 1,�...Y2.. <br /> Installation will serve: Residence[Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel❑Other . . -- .......................... <br /> Number of living units:-. .. Number of rooms ... ....Garbage Grinder-7 .. . lot Size . .. .. .. ..'.:. .�, , :.. <br /> Water Supply: Public System and name .._ 61,. ........................... ....... ............Private'' <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Sandy Loam C] Cloy Loam 0 <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,) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size - � .0 x. ©.. .._... Liquid Depth ...<$...... ...........� <br /> Capacity c a& 4__,T . - .. Material. Na. Compartments <br /> Y1�Iapa .s <br /> Distance to nearest. Well _ _ . ....................Foundation Zq.r. — ..' S <br /> Prop. line :. ... ......,.5 <br /> LEACHING LINE No. of lines Length of'each,line .... 'U' el...... Total Length .... ;X7.. �........: <br /> Box-- ,A(r-Type Filter Material . Ay....Depth Filter Material .... I .. ... ... .......... <br /> el <br /> Distance to nearest: Well .4L_V1_�_.._.... Foundation �. 7'_ _..._.. Property LineC.~.... ......... <br /> SEEPAGE PIT { j Depth . ....... Diameter ................ Number . Rock Filled Yes ❑ No <br /> Water Table Depth ................................................Rock Size .-.............................. d' <br /> Distance to nearest: Well .. ............................Foundation ..... ..... ....... Prop. Line ........................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ._.._.. .... ...................... Date ........... .. ..............._.......1 <br /> Septic Tank (Specify Requirements) �e%` 'L ................... <br /> Disposal Field (Specify Requirements) .._.... . <br /> _._... - --- ---------- - ----------- --------------•-- .................................. ._.--.....__............::............ <br /> (Draw existing and required addition on reverse side) <br /> I hereby 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. Home`ownor or (icon= <br /> sed agents signature certifies the following: <br /> "1 certify that In the performance of the work for which this permit is issued, I shall net employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .....-- •. ... .......... Owner <br /> BYE - ! 6 '`��.. !/ ".- Jitie ±" .:.:....... <br /> (If other than owner) <br /> R RTMENT USE ONLY <br /> ..._. DATE <br /> APPLICATION ACCEPTED BY <br /> f <br /> ` � <br /> BUILDING PERMIT ISSUED ....-.. _.. _. .. - .._..._....:.. .. ....__.. _DATE - <br /> .. <br /> ADDITIONALCOMMENTS . ....... .. ...................._.......................,.................._.... ................................... <br /> ... .. --- <br /> ......................... .. . ._ . ..------ <br /> ........ <br /> Final Inspection by: ......... . ... .. .... ...i. .. ....__ ...---......_........ ... ......... .. ............ ........._Date .. ... <br /> ....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R <br /> .1 <br /> E;.H.13 241-'68 Rev. 5M -. __ 7/72 3 M V <br />