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FOR OFFICE USE: -� •� APPLlCATiON FOR SANITATION PERMIT <br /> ...............................:.................. i <br /> (Complete in Triplicate) Permit No. .7_Y..�.. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> 1 <br /> Application is hereby made to the Sari 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 /> �/ , s� <br /> J08 ADDRESS/LOCATION .._l.. '� �.._.--_- ..T._. . -----� ........ ........•.-.-----.--.----.•--._._._....CENSUS TRACT .:.5.-......_..•._..... <br /> -0 r <br /> Owner's Name .............. ..... dt: .f - ��5 .e•�r.. . ' Phone .................................... <br /> --• <br /> Address ...._......•--•--...,/, f ........... ..tge......................................... City ...._.:. ...... <br /> . -•-----•-•----•-•-•-------- •------•--•-•....---••---... <br /> Contractor's Name .-- :..... }'� license # .._... Phone .............................. <br /> Installation will serve: Residence [] Apartment House] Commercial Xyraller Court <br /> Motel ❑Other ............................................ <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder ....____ Lot Size ..--.__-.--.--------•----................. <br /> Water Supply: Public System and name ......•••---••--......--•---•----.....................---•----.....__....._....._._..........•--.......:..._...Private <br /> Character of soil to a depth of 3 feet: Sand'❑ r Silt❑ -Clay ❑ -Peat❑ Sandy Loam Clay Loam ❑ O p <br /> Hardpan-❑—-i -dobe-C❑—NII-Material-.------�._ If-yes--type-_...,:._ <br /> {Plot plan, showing size'of lot, location of. system M relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) <br /> le <br /> PACKAGE TREATMENT SEPTIC TANK Size._.3.1.1.X..1X.�r........:............ Liquid Depth _X.................... <br /> ' �as�. <br /> Z <br /> acity....� ��/...._ Type.... .. ........... Material_..__ _Q �.: No. Compartmentsance to nearest• Wel( <br /> ....................................Foundation ... .................. Prop. line ............... j <br /> LEACHING LINE No. of Linen-j.......7.............. Length of each line------ V�---_-_.--.--. Total Length ...?`�. ..___•__.___.. <br /> ii � f � <br /> 'D' Box ....I...... Type Filter Materia! _._ _.._.....Depth Filter Material ' ...... ......... <br /> Distance to nearest: Well .._./ f' Foundation' ../Q.........-..... Property Line ...... . <br /> SEEPAGE PIT [ Depth .................... Diameter __.............. Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth .Rock Size <br /> Distance to nearest: Well <br /> ...................................,....Foundation .................... Prop. Line ................. <br /> -•--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------_ ............. Date .......-...._--_-..___._____-----j <br /> Septic Tank (Specify Requirements ) ........ ; <br /> Disposal Field (Specify Requirements) ----------------------------------------------- ..................................._:-•---•-------•-•-•------------------------------- <br /> ----------------------------------------------------------- ----------........-------................................-.........................................................I........................ <br /> t <br /> .--- —(Draw­eXisting and-required-addition—on--reverse-side) •- <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. Home owner or Hcon- <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 I, <br /> ----- ---------------------•------------------ <br /> 'I <br /> By ................. -••--••----- Title <br /> --------•.............................................................. <br /> (If other than ` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _....�i _sir.--_•._ ........: DATE <br /> BUILDING PERMIT ISSUED ............................................................... ...........DATE <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------------ <br /> ........................ ---------------.�,� /. _.....1 "..__.. ....................................................._ - -- -----.......................................... <br /> - •----•-------------- <br /> ------•-----------------------------•- ..:�.. --------•• :-- - --------------------- .......--_....... <br /> Final Inspection hy- _�/ /�/ _. ��/...• Date ...... ...............�,. <br /> J7. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r to 13'24 1.-Ali Qn„ sru 7/72 3 M <br />