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.... FOR OFFICE USE: <br /> .................... <br /> ... � APPLICATION FOR SANITATION PERAAR / <br /> :n........ ................. <br /> it <br /> Perm �No�,�Z <br /> (Compteto in Triplic+atoll .. <br /> �.. ............................... ........ / <br /> ......................................................... °"• This Permit Expires Z Year From Dswl"ued <br /> Date lssued 6. a...� <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 is made in compliance with County Ordinance No. 544 and existing Rules and Regul�otionsc <br /> JOB ADDRESS/LOCATION ..._L..�.. ,. 0.^^.,-. ��` 44 /........`~..?`........................Ct'stVStlS TRACT .......................... <br /> Owner's Name ........._[q.-- ...F�. C�. .!4 .' ...Phone <br /> Address <br /> 4.. L .. 2 a 7 + <br /> f... ..............,._......•...........f City ../1� d- / 1. ......_...._._._. a. :......... - -... <br /> Contractor's Name ..... -�.. 5�.. .................................................License ih ........................ Phone 5 �'Z <br /> Installation will serve: Residence[R-Ap-artment House f3 Commercial OTratlor Court 0 <br /> Motel 0 Other............................................ <br /> Number of living units.-_;!-:- Number of bedrooms _: ......Garbage Grinder ............ lot Size ............................................� <br /> Water Supply: Public System and name -.- 0 <br /> .....- -f:�....... ......_ ................_.... ..�............ .,......, ........._.._...Private <br /> Character of soil to a depth of 3 feet.. Sand 0 Silt Q Clay ❑ Peat 0--. Sandy Loam o day Loam O <br /> 0 Adobe Fill <br /> Hardpan Material............If yes,type............... .. ..... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on 1 reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permWW if public sewer is available within 200 feet,! <br /> PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size................................................ Liquid Depth .......................... <br /> Capacity .................. Type -------------------• Material...................... No. Compartments ...................... <br /> Distance to nearest: Well ............................ ......Foundation ....... —........ Prop. Line ...................... <br /> LEACHING LINE [l�K No. of Lines ..........I............ Length of epch line.......4.0...f-7t. Total Length ..j?1 ........... <br /> 'Q' Box .....V... Type Filter Material Depth Filter Material ..... . ............................. <br /> Distance to nearest: Welk/ ..J t-------. . _ Foundation ....................... Property Line ........................ <br /> Depth Div' star .�� ���'Number ......................�..... Rock Filled. Yes No <br /> 5 v pr Water Table Depth ....•. .�1�� �--•--...-- .......Rock Size .. .er1. ..(, ........... <br /> I <br /> Distance to nearest: Well ........................................Foundation .1� .. !..... Prop. Line ....................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit 9# ............................. ............. Date ..................................) <br /> Septic Tank (Specify Requirements) ----•- _ . ...................... ...._,.......... <br /> � / .............. <br /> Disposal Field (SpeFify Requirements) t.... ..,.... .. .. ........1 ....- �n. �._.._....d'.`...d.....A ................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work wall be done in accordance with Sen Joaquin <br /> quin <br /> County Ordinances, State Laws, and Rules and Regulations of the Scut Joaquin Local Health:.District. Home owner or Itan- <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 /> SignedC ''-``.� .�-� _ Owner <br /> BY --- - ---_--------------------------------------------------------------- ---------- <br /> ----- ----------------•----•---- -----•---- J'itle ..-•---•------. --.......--------...•-----...--------.--..._._..-•-•-•-- <br /> (If other than owner) <br /> R D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . .. . ................ .................... DATE -1. •3°- 76 ... ...._..-- <br /> BUILDING PERMIT ISSUED ...... -------•-- --..... DATE ,.-.-.-. .---------••--- <br /> ADDITIONAL COMMENTS ...-.................. - ---- ----•----_.... ............................... - - .. <br /> .......... .........••-----....-----. .----- --_........_... ................................. <br /> ------------ -------• .............. ....--••---•----•.. ........_._.... .. <br /> _ _ ................ _ ��...................... <br /> ............ ................. <br /> Final inspection by: ..-,. °:max is - -..-.------ ......... <br /> ---- --------------------------------- <br /> .. ----- -- .. to . ... _ . _-_ ....... <br /> EH <br /> J 3 2!t 1-6f3 ifev. SAN JOAQUIN LOCAL HEALTH DISTRICT $/7h 3M <br />