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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .....................•--•---.._...._.__..._ <br /> .................................... <br /> (Complete In Triplicate) Permit No. <br /> d I <br /> Date Issued <br /> This Permit Expires ? Year From Date issued Da ""--'- <br /> Application is hereby made to the Son 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 /> JOB ADDRESS/LOCATION .....1�QZ_;- .`,T:_-1.... <br /> . ; ..............CENSUS TRACT ................ <br /> .......... <br /> Owner's Name _.._ _. .lV - _.1.J� �- _ l" f <br /> U �- _. -L�.�.--�---...!�1:-.rlx1..............•----• Phone ........... <br /> Address ... .........:5;� le ......-.......................... ........... ...................... City <br /> r coq <br /> ... ............... ............................................ <br /> Contractor's Name , i•/� ---- off <br /> --------- ....................•-•---.......Liren:e �.��`?=�.�s'..�... Phone .,: 2? ..:...../ <br /> .....•--- <br /> Installation will serve: -Residence IP Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other................. .......................... C_ . <br /> Number of living units.-/......... <br /> Number of bedrooms ,?.......Garbage Grinder ............ Lot Size ..... ...................................... <br /> . <br /> Water Supply: Public System and name ........................................................ .................................. ....Private ❑ . <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loam fa Clay Loam ❑ <br /> Hardpan❑ Adobe❑ Fill!Nater€al ............ if yes,type ............... ............ y.* <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATIONS JNo septic tank,or seepage pit permitted if public sewer is available within 200 feat,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK f j r Size................................................ liquid Depth .......................... <br /> C <br /> M. <br /> Capacity --------I........... Type ................ Material...................... No.• Compartments ......................T' <br /> Distance to nearest: Well. ....................................Foundation ...................... Prop. Line .......................r <br /> LEACHING LINE [ j No. of Lines .._..... ----- Length of each line......................... Total length l <br /> . <br /> _...... ... <br /> 'D' Box ........:... Type Filter Materia{ ..Depth .Fitter Material <br /> Distance to nearest: Well ........................ Foundation ..................,...... Property Line ........................ N <br /> SEEPAGE PIT [ ) Depth .................... Diameter Number ..__......_... ......... Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ---------•_....................................Rock Size ................................ O <br /> Distance to nearest: Well ........ ........................ Foundation .................... Prop. Line ...................... . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........................ _--- -- Date .................................. <br /> ) <br /> Septic Tank (Specify Requirements) ........... ------P�•-`�-� ... 7W�Y.��-.......................................... <br /> . ...... <br /> Disposal Field JSpecify Re uirements r" <br /> ----------•--•--•-•.............. <br /> ______________________________________________ <br /> {Draw existing and required addition on reverse sidel I <br /> 1 hereby certify that I have prepared this application and that the work witf be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and IRegulatiohs of the San Joaquin Local Health:District. Hence 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 become subject to ork n`s Compensation laws of California." <br /> Signed ------- l.__ Owner <br /> By ----- ---• • ------- ---------------------------------- •--- -------Title;.--------_..._ .._._... ' <br /> (If other than owner)-_,� ` <br /> FOR ARTM T USE ONLY ' <br /> APPLICATION ACCEPTED BY ........_. -c_. .__ .. - --------------------------------------------------- DATE ..3 .�p ._Z�'........._----.: <br /> BUILDING PERMIT ISSUED ..............................._._ ---------_DATE ___--- ...... . <br /> ADDITIONAL COMMENTS-- <br /> - <br /> .--.--.- <br /> ------ --•- <br /> ----- <br /> -.-.-.-.-.--e--- <br /> ---.....__.._------ ------------••---•-_...---------....---- ---•--------------------•--- -----. <br /> ----- --•- • - ------- ----- • ....• -- <br /> Fina{ Inspection lay: .. - .._....Date ..S -?EH . <br /> 13 24 1-68 Rerr. � 9,�.-... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> T <br />