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Fes..OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - R <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No. ___� _✓ ._ <br /> ------- ----------------------------------•-• <br /> _:-__-________ ------------------------------- ! This Permit Expires 1 Year From Date IssuW <br /> Date Issued <br /> Application is liem$y made to the San Joaquin Local Health DTStrict"f'or a permit to-construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> -l. -T , Qp <br /> JOB ADDRESS/L0CA 1`Olo�9,5__Z�__-__------5�----l-A�[_I_(�RT-----� -----------------CENSUS TRACT .._. '--5. ...... <br /> Owner's Name = `t� - LSI- -- -- �---------�-------------------Phone ----------- ----------------------- <br /> it � -h-P-0 R� - <br /> Address -----------�,V3r - ��? / �� 1 City - ----------------•------ <br /> Contractor's Name ------e2b1LN '?- --------------------------------------------------License # --------- -------------. Phone ------------------------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial [-]Trailer C oVo <br /> Motel ❑Other --------/--�-------------------------------- <br /> Number of living unit <br /> s:____1----- Number of bedrooms ----l`__....Garbage Grindery�Lot Size --- i _ 1��-.5-------- <br /> Water Supply: Public System and name -----------•---------- -----------------------------------------------------------------------------------------Private ©� <br /> Character of soil to a depth of 3 feet: Sand ❑'` Silt❑ Clay ❑ PeatSandy Loam;OClay Loam E-]Hardpan ❑ Adobe E] Fill Material - If yes,type ___________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seeps it permitted !f ublic sewer is available within 200 feet,) '^ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size___�1�_��___x_.__)—____ _ Liquid Depth -----------., r <br /> Capacity 1 P-1F19Material C No. Compartments -.... -.... �► <br /> istance to nearest: Well ___30___"f'_- Foundation ___�_ _ Prop. Line$_____.'�^.J, <br /> LEACHING LINE No. of Lines __-_2--- __ Length of each line-_--7jV--------------- Total Length _____-1,XV....... (� <br /> D' Box/` v <br /> ��_ Type Filter Material AW-CK.-De h Filter Material ____ _� _______ _ ____ __ <br /> (•. _...__ .. <br /> Distance to nearest: Well s _Foundation _10__x'--__ Property Line -_�=+... <br /> SEEPAGE,PIT [ ] Depth __ ------ ___ __. .Diameter --: _: '__`_ Number _____-_ ___ ___________ Rock Filled Yes '❑ No i❑ <br /> Water Table Depth ----- ...... -------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------_____Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-_.-__•-----__--__________) <br /> Septic Tank (Specify Requirements) ___ ________•__________________--______-_-___----- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------- -----------------------------------------------•-------=-------------------------- --------------------------------------------------------- <br /> (Draw existing 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 licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is. issued, 1 shall not employ any person in such manner <br /> as to beco ubject to W rkmaCCpensatior�la '{Qrnia!"'Signed __ __ _ _ _ _ ______ ________ Owner <br /> BY --------------------------------------------------------------------- --------------- i ---------- ------------ ----------------------- <br /> -------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -{- <br /> -- -(R--�--1------------------------------------------- ----------------------------- DATE --- <br /> BUILDING PERMIT ISSUED --- -- --------------------------! -- ---- _DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS ------------------ t <br /> ----------------- <br /> --------------------------------------------. ----- -- ----------------------------------------------------- ------------------------- ------ ---------------------- <br /> r <br /> - -- � b p 1' AI -- - -- • --- --- ----•---------- ---------- <br /> s <br /> --------------------- -- - - <br /> Final Ins esti - Date <br /> -.. <br /> r <br /> -- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />