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FOR OFFICE USE: . <br /> APPLICATION FOR SANITATION PERMIT l <br /> {Complete in Triplicate) <br /> Permit No. ..... I <br />.........................................•---- -----_-- <br /> 1 Date Issued - ........�L� <br />.............I.,........... This PermiVExpires 1 Year From Date Issued <br /> 2- 5'--0(-O 3 0 <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 IWI <br /> e in compliance wi County Ordinance No. 544 and existing Rules and Regulations. <br /> vr� o r fc '�`� ` <br /> JOB ADDRESS/LOCATI N �'� ---------•- • ... /l� ._. ._r. V......._...CENSUS TRACT .. `��...._ <br /> Owner's Name _.... !✓ (�t�- a Phone ......__.. <br /> Address .� � � '. • k.f1 'T............. <br /> Contractor's Name ...... "flCtAt f ..---------- ---...License # ...'S�.7,5Y.7� Phone <br /> Installation will serve: Residence E]Apartment Ouse❑ Commercial ❑Traailr Court 0 <br /> Motel E] Other . --- --:. <br /> Number f living units:.. ....... . Number of bedrooms ------------Garbage Grinder Lot Size ..� '` ._...._.. <br /> Water Supply: Public System and name _ .-- ------ t------------_------_--_ .__......._Private ❑ <br /> ... . �. <br /> Character of soil to a depth of 3 feet �Sa'❑ Silt❑ Clay [] Peat❑ �Sand� Lo J Clams y Loom P� <br /> Hard an u A' abe ❑ Fill M-bterial _._... ••... if Yes,type ..................--------- <br /> (Plot <br /> ..... .. "- <br /> ` _ <br /> (Plot plan, showing size of lot, locotion.-of system in relation to wells, buildings,Yetc, must be placed on reverse side.) o <br /> NEW INSTALLATION: (No septic tank o�r s�e�epage pit permitted if public. sewrr is oJoilable within 200 feet,) � <br /> PACKAGE TREATMENT SEPTIC TANK' _ i f <br /> I � � ize._..---:��- - . ............. . . Liquid Depth ---�j.�.........._.__.. . <br /> Capacity) .. .._... Type . .... ......... M1 .terial. . _.. No. kC&Aoar'tr'he ------ _.- <br /> nts -.•,fi <br /> f s ;Ii, ► <br /> Distance to nearest: Well .-l _,." .. . .........Foundation ..IQ._'t`_..... Prop. Line ...... <br /> LEACHING LINE No. of Lines ._._ ..... Length of ea line .. ...�d..... K j otgl Length <br /> (� <br /> +� .» 'D' 13ox _.. Type Filter Material _.-Depth Filter Mate—F151-2 ­------------- <br /> i <br /> ------------- �. <br /> .t ... <br /> Distance to nearest: Well ..l.Q {'t'_. ... Foundation ..../..t7.. .._.-'"it- "Praperiy Line5........"..._.....f <br /> SEEPAGE PIT [ ] Depth .. . ... ..._.... Diameter . Number . Rock Filled Yes ❑ No i❑ <br /> -"' Water Table Depth _.. --- ....---•...Rock Size ...:........... _---•--------- <br /> a3 F-v '4 <br /> D tante to nearest: Well r ndgtion ......... Prop. Line <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ..................... ........ Date --------....:..................... <br /> I <br /> ptic Tank.(Specify Requirements) ..... ._. .. srs._ .. <br /> i posaf Field (Specify Requirc�nts)'' :.--:-!"!K.c. .............. <br /> _. <br /> ------------ <br /> -_._.. �.l ... .... ... ... ........................................ .................... .................... . .............. <br /> (Drdw existing and required addition on reverse side) <br /> 1 lereby certify that]j0 ha`elprepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Stage Laws, and Rules and Regulations of the San Joaquin Local Health District. Herne 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 Workman's Compensation laws of California." <br /> Signed .:.. ... --._.... _------ -----------------•-•-- ---•-------------- Owner •••�- <br /> By .... ` . Title .... �1 '.. ................ <br /> {If o er n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... 'L. _-------' '- ----•........... ............ .............. ................ <br /> .............. DATE .....2., .�_.--.. ........ <br /> BUILDING PERMIT ISSUED --------- ---- - DATE . .-• -------•.._ <br /> ----.---. --•---........ <br /> ADDITIONALCOMMENTS .......... . ` - -------------•---------------._.........------- ' ----...._..---------._....._--'-----...._..._.:........._....---...------- <br /> ....................................... . --- -- ---11........K...... . .. .. -- ---------- <br /> - ' .. <br /> ----- .............. <br /> Final Inspec i . .... ..... .......... ...................Date ....... .r. . . ._._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E._H. L3 241-'68 Rev. 5M -- - - - --- - — - - 7/723 , -- <br />