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FOR OFFICE USE: ` ! <br /> APPLI!CATIO R�SANI'TATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> i -- ...............75 <br /> ......•................•-•-----.........-..--.......----- . e This Permit Expires I Year From Date Issued Date Issued f-- <br /> (zit o C!•a-'-f3 <br /> Application is hereby made to the San Joaquin local Health District for .a permit to construct and install the work herein Qy <br /> rf <br /> described,ffIh�i/sf�a/p�plication is macLein tomplirince with County Ordinance No. 544 and existing Rules and Regulations: t <br /> JOB ADDRESSAOCATION ..-. ' f -_... ..-. x196 1 1, -. ........CENSUS TRACT ..............•....... <br /> .... . <br /> t � <br /> Owner's Name ...�7-'�.��.. ll+ ��� ,.,.-F---------------........ ........ -• • ---------------.............Phone ................. ... <br /> Address �. <br /> ,�................... ... ...... Cityf-,e �1�1�'- .................................................. <br /> Contractor's Name ...�s� '�w .r t� �'�-....... ---------- ---------------------License # I,C �. -. Phone Vll�e eK..,... <br /> f <br /> Installation will serve: Residence ❑ Apartment House-C] Commercial ❑Trailer Court C) <br /> Motel ❑ Other ,�'.� , <br /> Number of living units... .f.... Number of.bedrooms .. ,_..'-.Garbage Grinder �/f.-... Lot Size .................... ; <br /> W6ter4upply: Public-System and name ..._----------------- -••---`.t`_....:--.-----.---........ <br /> ......-------------_-----------------------•--...Private; [ <br /> Character of soil to a depth of 3 feet: Sand L7 Silt❑ Clay ❑ Peat❑ Sandy Loam] Clay Loam ❑ <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 /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size<;...................... <br /> Liquid Depth .......................... <br /> Capacity .. . ------ Type ................ Material............. ........ No. Compartments <br /> f Distance to nearest: Well .`... .......... ...... ._... <br /> . Foundation ............. ..... Prop. line ------._.._.-----._ -- <br /> c <br /> LEACHING LINE [ ] No. of Lines .....,:Length of each line.`.�....,.. . ..r.---..-....- Total length -.- <br /> _— Y---- .....� , <br /> 'D' Box .--.-. -. . Type Filter Material .--.--...._....Depth Filter Material .... ............----------------.---------- �p <br /> Distance to nearest: Well ......._-'.---- ----- Foundation ........................ Property Line ........................ <br /> SEEPAGEPIT [ j .� Depth Diameter .....- Number ---------- --• Rock Filled Yes ❑ No-(]` <br /> Water Table Depth ..._.---------------------------------.....------Rock Size ......... .. � ? <br /> Distance to nearest: Well .....................................Foundation ... ...._ ....... Prop. Line ---------- .......... 9 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...................................- Date _.-..------ -_--_--...._-.._.) <br /> Septic Tank (Specify Requirements) .. ........... ....... .... <br /> Disposal Field (Specify Requirements) ..... �f1--- .- .... ..../ �r�' .P .r..... <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 J <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or ficen- <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 subject to Workman's Compensation laws of California." <br /> Signed .... .. ........... . ...... ........ .... ------ Owner <br /> BY ..-. ... �. v P`' .". ............................. <br /> .. Title . . <br /> (if r than owner) <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ....... ......... ............ ........ DATE .....��:..�`. . <br /> BUILDING PERMIT ISSUED ...... DATE <br /> ADDITIONALCOMMENTS ..... =. .. ... ---- -- ------------•----------.........---........ .........- --------------- ................---..---....-........-..... <br /> .......-•----•--------..... -•f .. r.... .................--------- -• -----.......... ...........- -...-...--------- ----- ------------ <br /> Final Inspection by: ------- - --- --- - ...... --------- ..........Date .._ . .-. .......,.......... <br /> N AQUIN LOCAL HEALTH DISTRICT <br /> u 13 24 <br />