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FOR OFFICE USE: <br /> fi' ' .` APPLICATION FOR SANITATION PERMIT <br /> ... - „. ....... <br /> Permit No. <br /> j�Y ....... <br /> f Al (Complete in Triplicate) <br /> Date Issued <br /> "�- �,,,�,,,,.,'..•,.. 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 and install the work herein <br /> described. This application is made in compliance with Count Ordinan 549 and *sting Rules and Regulotionss <br /> 2NL <br /> JOB ADDRESS/LOCATj�ON i?-� 1 `� �-0F .. � �.} c? ........................CENSUS TRACT ......................_.. <br /> Owner's Name ..T.A.V ....�..� ? s� - Q...........-••.................. ... ............. .....................Phone 44W. n� ....3...� <br /> Address .... �, �� �!�i H 1. ... �1.!E:4 ........--••••••..... City• �.va,e f....................:................._............... <br /> Phone <br /> Contractor's Name .......-... �.._.__f ........... .:.........._.license # . -- <br /> Installation will serve: Residence KApartment House 0 Commercial❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:..../..... Number of bedrooms*_3......Garbage Grinder ............ Lot Size 1�....: ... ....... <br /> Water Supply: Public System and name ......................................_....__. -� !! ..• -•-•-••--•-•Privatg, 'S <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam I'W" <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 /> P _, f s <br /> PACKAGE TREATMENT ] SEPTIC TANK / size..... ..... ..................... Liquid Depth ... ���.._......... <br /> Capacity ..�.nQ(Q...: Type 6Z art Material ��!�!�! ..... No. Compartments ....... <br /> Distance to nearest: Well ....................................Foundation ....L..........._.. Prop. line ...........- <br /> Len Length f eocb..line..... ............. Total Length c� <br /> LEACHING LINE No, of lines �' g �• g •........... <br /> te <br /> 'D' Box ...�[....... Type Filter Material �,...Depth <br /> Filter Material ........�s ...............•....�::_._� <br /> Distance to nearest: Well . ?fix-•.:. .. Foundation ....?-�`�. ........ Property line ...... a.........:. <br /> .�., ........ Diameter <br /> 04, ...... Number ..... ........... .... Rock Fitted Yes $',� No Q <br /> SEEPAGE PIT 1J4 Depth /X'Wl <br /> Water Table Depth ...7i.[....................................Rock Size __•••...7:••••..••r........ <br /> Distance to nearest: Well.•.14-.0-2 ................_...Foundation .. .P-:.------- Prop. Line .6 ............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> SepticTank (Specify Requirements) -------------------r.-•-..._.................•._.....••••..._.................................:_..........._.............---______......... <br /> DisposalField (Specify Requirements) ...................-•-•--...._..................................•---........._..............-•----••••._................_....._....._. <br /> ................•---••---...-------•--.....---................-----.......------••-•......._.....•-•---•---••---•--•-•---...--•--....•-•••--•••••--•--....----•-••--•....._..._._....-•----....__._....._. <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 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 <br /> su a to Workman's omp aflon laws of California." <br /> Signed •, iF1_ '. . .. ..... ................. Owner <br /> By .......... ......................................................_.- - •• ...-. ............ Title . "^ <br /> ..._.........-----..• ........................... <br /> : <br /> (If other than owner) <br /> ~��`-. / <br /> FO"EPARTMENJ USE QNLY <br /> APPLICATION ACCEPTED BY DATE ...... �`.1.. ....'• <br /> BUILDING PERMIT PERMIT ISSUED .... ....................................... . .... ............... DATE <br /> ADDITIONAL COMMENTS ..... . . ... . .. ....... /��.�- '••-• ............... ....... <br /> .................•---.........•........... ............��. .......... . ... ........ ... ............................ _........... <br /> ••-•..............•----•_..---....... ........................_.. .........................................................-........................................... <br /> . <br /> Final Inspection by: Date . � ..: , <br /> .. :r. <br /> SAN JOAQUIN L L HEALTH DISTRICT <br /> E HH.L3 241-'68 Rev, 5M 7/723M CO <br />