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FOR OFFICE APPLICATION FOR SANITATION PERMIT USE: - . <br /> ' <br /> - --- -- - - <br /> '------------------------ ------------ --- <br /> A-~-�--Momplete-in Triplicate)��-•-•-----�---_ Per77_/:w_6__/_ <br /> mit No. __ <br /> 1 1 r <br /> This'Permit Expires 1 Year From Date Issued. Date Issued <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,_549 and exsting.,RVIe and Regulations: <br /> J G <br /> ------- <br /> JOB ADDRESS/LO ATION . b `S' `------- wr1 J�-'"----_�-- = --�---:,-_CENSUS TRACT -'5-'Z7/ <br /> Owner's Namet <br /> �•Ccz�_ �i:��z�-_1-�--- -- -------------------------- ------------------------------------ii .__Phone -'------"----------------------- <br /> Address �/l r !'s.�-c 0_2AdAke Cit --- ------ <br /> -------------------1 <br /> Contractor's Name ----- � License # Phone - <br /> ' Installation will serve: Residence [] Apartment House❑ Commercidf:❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Lj <br /> F <br /> Number of living units:--------L Number of bedrooms 3_._-___Garbo e Gri der ________ Lot,Size _( X A10-42--- <br /> -------------- <br /> - .moo_zr� --- <br /> Water Supply: Public System and name ____ -- _;- �� -__ i Private ❑ <br /> F - � <br /> Character of sal to a depth of 3 feet: Sand' { Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe-E] Fill Material ----------j_f If yes, type _w+__a___'-_______--------------- <br /> r <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings!/etc. must be plac;ed on reverse side,} <br /> NEW INSTALLATION: (No septic tank or seepage pit-.permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANKSize <br /> ' 3 t — y <br /> [ {. =_ �Liguid Depth --- <br /> ` ._ `- -----.- <br /> CapacityType Material ....... mp _ Z . <br /> ..... W <br /> Distance to nearest: Well _^P­✓ _ _ _'__Foundation `C1/---------- Prop Line _ �___________ <br /> LEACHING LINE j,Fj-____No. of Lines ___ _______________ Length of each line______ _ --- ____ Total Length 2/4?_-____________- d <br /> D Box ------------ Type Filter Materia! _ `----_---__:-Depth-filter-Material <br /> Distance to nearest: Well ___G �1mre-..... Foundation ..../4;;�-------------- Property Line __ '________________ <br /> SEEPAGE PIF Diameter ______________ _ Number <br /> ----------------- ---------- Rock Filled Yes ❑ No ❑ <br /> [ ] Depth --------------- - <br /> Water Table Depth `-------- ------ '=- --------------Rock Size ----------------------- <br /> Distance to nearest: Well - -- -------------=----- --------------Foundation -------------------- Prop. Line ...-•----------------- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# - <br /> } <br /> Date______- -------- <br /> Septic <br /> -------Se tic Tank fSpecify Requirements)uir <br /> ements <br /> Dis osal Field (Specify Requirements) ------- - ----------------•--• ------------------ -------------- <br /> ------------------------ ----------------------'-------------------- - - ------------------ I pp <br /> ------ <br /> i <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 Lavrs, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: , I <br /> "I certify that in a performance of the work for which this permit-is-issued,hshall not employ any person in such manner € <br /> as to beco e j ct to W kman's Com ens tion laws of California." <br /> Signed 1 <br /> .. <br /> Owner <br /> BY --- - - -- -- ---- ----------" Title <br /> ------ ------------------------------------------------ <br /> (if other than owner) <br /> FO DEPARTMENT USE ONLY J <br /> APPLICATION ACCEPTED BY - --- - -----�------------------- '-------------- -_..------------. DATE --- 1 J�/ <br /> BUILDING PERMIT ISSUED -----'--------------------------------------------------------- -------DATE <br /> ADDITIONAL COMMENTS <br /> - ------------------------------------------------ ---. -------------------------------------------------------------------------------- --------- ---------------------------- --_- <br /> -------------------------- <br /> ---- --------------- -------------------- --- - -- --------------------------------- <br /> ---------------------------- ---------------------- <br /> - --- ----- <br /> - � <br /> Final inspection by: � <br /> ------------------Date � _�/ __ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M i <br />