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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT <br /> -�---�.-Jl�- Permit No. _7�"---- <br /> (Complete in Triplicate) <br /> j��}f1 Date Issued ___�_:1Z _z <br /> ------------------ <br /> ----------- �--_I____ __- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son 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 /> f G� <br /> ---Y - ----- --_'l_�- ----------- - <br /> --- --- !J� --------.CENSUS <br /> TRACT -----JOB ADDRESS/1_0 A ON � ---- ------ -------------------- <br /> -------------------- <br /> ----------- <br /> - <br /> -------- ----------------------------------------- <br /> ----------- <br /> � --------------•-----•-------- '---- <br /> � <br /> a <br /> -Owner's Name � c--------- Phone --------------- <br /> Address ------------------ <br /> ---- ---------- c ---- - - ---- - ---•-�tY ------ <br /> Contractor's Name - -----------------License ------ Phone = _ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial : Trailer Court ❑ <br /> Motel ❑ Other __a_r. ----------- ------- <br /> Number of living units:------_""l Number of bedrooms _ __Garbage Grinder _ ^-___ Lot Size .#___ _11a__�------------ <br /> I <br /> - r <br /> Water Supply: Public System and name ---------------------- --------------------------------------------------------------------------- -----------PrivateX <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt-E] Clay Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe V Fill Material Ar2____ 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 p'it,permitted if public sewer is available within 200 feet,)��//,y <br /> PACKAGE TREATMENT 1 SEPTIC TANK'f�/I � ize--- Liquid Depth ___.!___z._____....,_---- <br /> Capacity _�- _4_.p_______ Type ,Z-,VMTMateriaa_1,-_mac No. Compartments �_�). ____........ (Ohh <br /> Distance to nearest: Well --------------------------------._Foundation ---Ze-J__._------ Prop. Line __ ..- ----------- y l <br /> LEACHING LINE ---------No. of Lines -------I--------------- Length of each line-_h©[? -______________ Total Length __�_ .......... <br /> D' Box AX -- Type Filter Material - _-c_j�AC------Depth filter Materia! _____ _. -------------_.................. <br /> Distance to nearest: Well ------------------------ Foundation w----/d__J---------- Property Line. ............... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _____________ __ Number ----------------------- ---- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------------------------Rock Size -----=--- •------------------ ; <br /> Distance to nearest: Well ------_-i-------------------------------Foundation --------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------.-,------4`---------------------------- Date --------•-------------------------] <br /> Septic Tank (Specify Requirements) --------- -------------------------------------------------------------------------------------------------- -•--_ <br /> Disposal Field (Specify Requirements) -------------------• --------------------------------------------- ------------------------------------------- ------•--------------- <br /> i <br /> -------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- -------------- <br /> ------------------------- ----- ------ --------------------------------------------------I------------------------------------------------------------------------------ -------------------------------- I <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 !trot 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 = = <br /> ------------------------------------------ Owner <br /> B ---------------- ------- ---------t - P------- �� - Title _ �:x ✓ -�c�C ----------------- '----- <br /> (If other than owner) <br /> O PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---- =--- --- ---- -- -----------------.--------------------------------- DATE ----.-/,-�,�.����-------- <br /> = ----------------------------------DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED <br /> ADDITIONAL COMMENTS ------ --------------------------------------- -----------------``---- --- -------::_--------------- <br /> ----------------------------------------- f <br /> --- - -------------------------------------------- - -------------------------- > ------ <br /> - ---------------------Date ---- --- �� <br /> Final Inspection by: _ -------- <br /> -r / SA JOAQUIN LOCA: HEALTH DISTRICT <br /> E. H. 9 s 1768 Rev. 5M <br />