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PUR ®FFlCE USE, <br /> APPLICATION FOR SANITATION PERMIT <br /> ............,.., ..4�ff <br /> ...., .................... _ (.Complete in Triplicate) Permit No. ...��"-!:D. �/ <br />' . . This Permit Ex Eras p YearREron►DaM 4ssued .�:. °� `s ' <br /> Application Is hereby made to the San Jo ~ <br /> aqutn Local�t=leap`h�°'D'istilcf--ior�a�permlt�-to•�conatruct-and--Enstall�fhe"work herein <br /> described. This application Is made In compliance with County Ordinance No. -549 and existing Rules and Regulations, <br /> .17 <br /> JOB ADDRESS/L 1O 1 <br /> ' - . . .......CENSUS TRACT; ......................... <br /> Owner Name me �.. : . . ........ .. . .......�!. ..... .....Phone ...I... _....................._.. <br /> Address ................._. `"-V--,. - ' ..}. � <br /> Contractor's Name .. s' ^-,.. ... ................{ i .........License _ ... ................................ pp <br /> Install Phone .� .d�...:.�1...._.. <br /> Installation will terry � alder►ce , <br /> artment House❑ Commercial❑Trailer Court <br /> Motel-.n Other---------_------- -- ....................... <br /> _ �t <br /> Number of living-units.......... Number of bedrooms Garbage Grinder Lot Size <br /> Water Supply: Public System and name � �?' ._ � ..._._..... �Y�� ...............�. -..-----•--• .......... ..........---,...........-•-- , <br /> y.. ..# _Private�--� <br /> Character of-soil to a depth of�3 feet: Sandy Silt Cfa' � Peat w........................................... <br /> dy` .. ......... ..'..-------• <br /> r - - __E1 .., ❑ ,l Y ❑ ❑ San Loam 0 Clay`Loam ❑ <br /> Hardpan[J Adobe[]' tifil Material ............If yes,type_.._..... ... ............ <br /> (Piot plan, showing sire of lot, location of system In relatlon to wells, buildings; etc. must be placed on. reverse side" <br /> NEW INSTALLATION, <br /> � (No septic tank or seepage pit permitted if public sewer.is available within 204 #eet,l <br /> PACKAGE TREATMENT [ I SEPTIC TANK <br /> Size ... ................:............ Liquid Depth <br /> Capacity -c pe •_L Material.:.-•-•-------------- No. Compartments -.....----:.-- <br /> Distance to nearest: Well . ff>.:_ <br /> __________________Foundation _ .�........... Prop. Line . _ <br /> LEACHING LINE [ j No. of Linea .-a. ......- --:._^ Length of each line.- Total Len . .-.�.........,. <br /> F gth �!d <br /> 'D' Box --..... Type Filter Moterl dl ..__Depth Filter Mater€al ..-:... _-.-.-•� <br /> Distance s once to nearest: We ................i J... foundation ------............ , <br /> ._. .. Property Line ........................ , <br /> SEEPAGE PIT [ D Depth - .. Diameter '.-_: .. <br /> Number . Rock Filled Yes ❑ No CW ' <br /> r Water Table Depth ............................. ..................Rock Size ............. ........... <br /> Distance-to nearest: Well ................. ...-.................Foundation ...:............: Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit <br /> Septic Tank (Specify Requ€cements) ........................................ f -,............... <br /> Dote...........» -____.-__.. .� <br /> Disposal Fiera{(Specify Requirements) ...............................................•-----..............._..- .^N _--...... ..N. .^ .._....._...`...... <br /> .............. 1�--.. �• ,11.. ....._.....--------........_...._....•...........--•---........----..................., ------................................................... <br /> ........ ...... <br /> ........_...................................-•--...-•---.....--•--•.............---._................ <br /> (Draw existing and required addition on reverse tidal <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. Horns owner or Ilcen- <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 net employ aKy person in such manner <br /> as to become subject to Workman's Cqmpensation laws of California." <br /> Signed ....- 3 r • Owner <br /> 13y ......._..-- ..... <br /> .................................. title <br /> (1f other than owner) <br /> •..:................ ............. ;.................... ........... <br /> FOR DEt6UMVNT Y9 ONLY } <br /> APPLICATION-ACCEPTED BY....... --•... . DATE .., ..., - . . , A <br /> .... . . ........ ._ <br /> BUILDING PERMIT ISSUED ..................... <br /> ........ ....................................... ..................................._DATE .......................:................... <br /> ADDITIONA. COMMENTS ..................... <br /> _ ....__......................................... .............. ...................... .._.............................-.................._.... <br /> ........................... ......... ................. ............. ........... '" <br /> ............. ............................................ <br /> Final Inspettian by: <br /> Date .... <br /> EH 13. 2h 1-6F3 ... %..... ._.... �. ...... <br /> R° SAN JOAQUIN LOCAL HEALTH DISTRICT $/7h 3p1' <br />