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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ......................................... ........ <br /> 7_1 <br /> (Complete in Triplicate) Permit <br /> ............. ... . ............ - __ _ _ _... r.,. .._� .W . .. , _ P. .._it Na. ._ <br /> . <br /> .:. ..:..-: This Perrrtit#:xpires t Year from oat*Issued Date issued ./~.��:. <br /> ...... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> describer!. This application is made in compliance with County Ordinance Na. 549 and existing Rules and Regulations: <br /> y V ._ <br /> JOB ADDRESS/LOCATION ....3./.-/-S, ...:..)3 ./..Y..�..,�P(.el!7c-.-............... ......................CENSUS TRACT ....., <br /> Owner's Name 77P-�?-!'i.....A-4Q�.1...............................-•-- ••.---................. ................: Phone .. ..9.Q /..... <br /> Address ....3 ..1 .......�r . lea <br /> .. . .q.is.-i.j-t........................ City ......S .0 k].'p,&I..................................... <br /> Contractor's'Name ----.._ !'.C.�.:j... ..--- o ter <br /> ry <br /> •---- --- ---•.............................•kicense 0 .%z:S.40.YJ... Phare .yh.�..�'..��..0..7.. , <br /> Installation�wiif serve: Residence Apartment House gKommercial ❑Traller Court <br /> Motel ❑Other ....:.............I......................... <br /> . <br /> Number of living units:_.- .-_.. Number of bedrooms ............Garbage Grinder ... . ...... Lot Size <br /> Water Supply: Public System-and name ...... r�!. ..................---------•............................................_ v <br /> ....Private ❑ V i <br /> Character of soil to a depth of 3 feet: - Sand'❑ Silt❑ Clay-B Peat❑ Sandy Loam O Clay Loam ❑ <br /> Hardpan Q 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 an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer.is available within 208 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Z" . ,.Size......................................... Liquid Depth .......................... <br /> Capacity ...... Material.............. -- No. Compartments ; <br /> Distance. to nearest: Well ..................................:.Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ---------------------... Length of each line............................ Total Length <br /> 'D' Box Type Filter Material ...Depth .Filter Material a <br /> DlStance to nearest; Well ..:..................... Foundation ...................... Property Line ........................ <br /> ~SEFPAGi? PIT { ] i pip#h ................. Diameter �................ Number ........__ ................. Rock Filled' Yes ❑ No 0 <br /> Water Table Depth -T ". ..Rock Size . a <br /> r <br /> Dis#ante-to-nearest: Well :..foundation``:...�........ <br /> .---- Prop. Line <br /> -"� <br /> REPAIR/ADDeTION(Prev. Sanitation Permit�` ...:...........----------------------------- Date .:...:.......-.__....__..........J . + <br /> d0 ./�a_n <br /> Septic Tank {Specify Requirements}._.-_...1, -•--•----------- ----•-•---------- ecyr..� <br /> ......-•-•- i <br /> Disposal Field (Specify .t.h. . ......... <br /> . 1 <br /> +6* -• - <br /> --•------------------------ ........._............................ <br /> ................... <br /> -------­-------1­1-- - - .- ------ <br /> (Draw existing and required addition on reverse side) }} <br /> I hereby certify 1_hat�I_have prepared this application.and that the work will be-done in accordance with San Joaquitt 4 <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: 4 <br /> 1- that in the performance of the work for which this per nit.is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation icws of California." <br /> Signed .. ........_._ Owner <br /> 1 <br /> _ r---- <br /> BYTitle <br /> ±?T Gc .©._.j..-.-.- <br /> •--- ..._........ <br /> (if other than: owner} .. } <br /> " L r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- ._ <br /> ..-- ------ DATE , t.. ,77T.BUILDING -, <br /> PERMIT' ISSUED --------------©ATE -----------------... <br /> ADD#T#ONAL COMMENTS - ••-------• -------•------ -------.......m............. ....................................... ; <br /> ------------------------------------ - ------ ._ .:....._.. --- ------I------- <br /> --------------- --- ----------------- -----------------------------------------------------.----------------• -• <br /> .... <br /> ..inal.In ....Inspection <br /> ..... -----•------------=------ ---•---••---.:._.---._.-.------••---------- <br /> ----------- <br /> Final Inspection by: <br /> -------------------------------------------------------- _..._... . l -� <br /> . .............Date -...... / . _.�..r�...--•---....---- <br /> EH 13.2h 1-68 Rev 51 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7li 3g( <br /> �i <br />