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EOR OFFICE USE: ; <br /> APPLICATION•FOR SANITATION_PERMACiRIMP, <br /> ' --------------------"------ ._,--------------------- _' �,_ ._.._ ,-y -�f?•l4 <br /> (Complete in Triplicate) <br /> t No. <br /> ---- ---------- ----------------------------- <br /> Date <br /> __-- This Permit Expires 1 Year From'DateIssued + ©ate 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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - _ ._` .�_3(0 ----.-----------------CENSUS TRACT -------------------------- <br /> Owner's.Name ...)h b-21 -----I---i----v..c---.--- --------------- ------------------ <br /> 1-------------------Phone ------------------------------•---- <br /> Address -- :---/_ 43.3----- ----- ------------------- City ,�a-�'"---'�-------------- --- ----------------------------------------- <br /> . S�PtscT�,vk s r•U�� <br /> Contractor's Name ®_o_u l,As__-•.-- --------------------------____-- _- �Q!_C+�y`�G"License # _ "�---12-71---Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court`',❑ $ <br /> Motel ❑Other ------------------- <br /> - <br /> : Number of living units:_._. Number of bedrooms-__Y------Garbage Grinder ------------ Lot Size <br /> Water Supply: Public System and name ---------------`-11-°----------•--•----------------------------------- - ---------------------- --------------Private [A-*** i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat❑ Sandy Loam Clay Loaik%.o <br /> Hardpan ❑ Adobe ❑_ Fill Material ------------ if yes, type _--'------------------- I <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 withiri 200 feet,) <br /> y i a~ 'II /� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [Lj� 5ze_S:XlO_r.S',5- ------------------- Liquid Depth _�2_P ...__. <br /> Capacity J100 Type Pr1C;7CfK"rMaterialNo. Compartments <br /> i Distance to nearest: Well ----------_- p• <br /> -�-Q--------------- Foundation - - �Q-��--------: Pro Line -----�---------- <br /> •-•- <br /> ,(. I I 3 r �V I <br /> j LEACHING LINE [l No. of Lines -----q-_______________ Length of each fine------ ---------.------ Total Length __3_X0_'f-------- 1J <br /> 'D' Box .�1 _�__ Type Filter Material _-IS�CCk-----Depth' Filter Material ---/9. <br /> Distance to nearest: Well -----S ------------ Foundation ------/0-_---------l Property Line __s----------- <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter __________ .Number -------- ---------------- __ Rock Filled Yes ❑ No C) <br /> Water Table Depth -------------- W <br /> i -----------=- ------------------Rock Size ----------- <br /> x- i�_ A. <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ___-_-..___-_______- 11ZI' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______________________ -------------- Date ------------------------_-i-______) <br /> x Septic Tank (Specify-Requirements)------------------------------------------------- -=-_----------;--------,=-----------=---------------- <br /> ° Disposal Field {Specify Requirements) ----------- ------- ------------------------------------------=--------- --------------------------------------- <br /> ------------------------=---------------------- ------------ ----- ------------------------------------ ------------------------ -----------_------------ <br /> -------•---- --------------------------------------------------------------------------------- ------------------"---------------------------------------------------------------------------------------- <br /> t (Draw existing and required addition on reverse-side)-- <br /> I <br /> everse-side)`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 subject to rkman's-Compensation laws of California." . <br /> S n -- V-Ic4----------- Owner <br /> 13� • ------ Title <br /> (If other than owner) <br /> R �{ FOR-DEPARTMENT USE ONLY <br /> 1. <br /> N�y <br /> APPLICATION ACCEPTED BY ._. -- ---------------------------------- DATE - - -`�- _Z_�.- ------ <br /> ------------ --- -------------------------------- <br /> I� BUILDING PERMIT ISSUED - ------------------------------------1------------------------------__- :. .`-- -- -------DATE - <br /> ADDITIONAL COMMENTS ---------------------------------------"- ' <br /> - , • - — ,_ r <br /> ----- --------- -------- ------- , ------------------------------------------------------------------------------- <br /> - - -Final Inspection by: - ---------- - ----------------------------------- ---Date - ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M , <br />