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lki <br /> -FOR OFFICE 15E: - <br /> APPLICATION FOR SANITATION PERMIT I/ <br /> - r <br /> ------------ ---- --------- Permit No. <br /> (Complete in Triplicate) <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 /> describe. is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> OF <br /> JOB ADDRE /LOCATION .--._149-t�.SS]�---S--------V N P /�LZ'�— -- CENSUS TRACT <br /> Owner's Name .--V L---------------------fl-jY f - -----� I---------- -------Phone 2y2-2— <br /> Address � � <br /> 1� - ---------- --•---------- • city 0 --c-----`------------------------- <br /> ---------------------------- <br /> Contractor's Name .BW_NZR---- ------- I] -------License-------------------------- Phone --------------------------•--- <br /> Installation will serve: Residence A artment House Commercial : Trailer Court <br /> II Motel F-]Other ---- -- - --------- --- ------- <br /> Number of living units:___1------ Number of bedrooms __ __-__Garbage Grinder A1_0Lot Size -AC{ E '�-_-________ <br /> Water Supply: Public System and name -----==-------------------------- -------------------------------------------------------------------------_Private <br /> Character of soil to a depth of 3 feet: Sand❑ alt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan Adobe ❑ Fill Material If yes, type -__--____-_-----_---_--_-- t <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 seepa pit permitted if public sewer is available within 200 feet,) ! \ <br /> PACKAGE TREATMENT { ] SEPTIC TAN Size-- x t -_ _--_. ------------ Liquid Depth _ - <br /> Capacity TypeRk�--___Mb Material_C4 C-=----- No. Compartments -------------------- <br /> Distance <br /> ---- ----------- ..-.Distance to nearest: Well _-r-_�------------Foundation -----/112----------- Prop. Line ----5-------------- <br /> LEACHING LINE [ ] No. of Lines ------- ---------- Length of each line------7-5-------------- Total Length ----/ ............. t <br /> r . <br /> 'D' Box "`�--_---- Type Filter Material -lg©S __Depth Filter Material -------- --17----------------__---------- <br /> Distance to nearest: Well ----/00_77t--- Foundation ----/0------------- Property Line ----ti77---------_-- <br /> SEEPAGE PIT [ ] Depth -f ___- r"- Diameter-A-9- Number .-- '-.- ----- Rock Filled Yes No 0 <br /> Water Table Depth ---------------- ---------------------Rock Size <br /> Distance to nearest: Well ---- —--------------Foundation -------- Prop. Line _..--5-_______ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -_-___-_------------------------_-__- -- Date -------------.-_-------_---_---__-) <br /> SepticTank {Specify Requirements) ------------------- ------------------------------------------------------------------------...-_.---------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- <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, I shall not employ any person in such manner <br /> as to becom ject to Workm n's Compensation laws of California." <br /> Signed j � " Owner <br /> BY ----- -- - ----------- ----------------------- ---- -----------------/EPARTMENCT <br /> --- Title --- - ------- <br /> (If other than owner( <br /> FOR USE ONLY <br /> APPLICATION ACCEPTED BY -----�,-R-0--------------------------------- -------------. DATE ---5.--,rp- -6z -- ---------- <br /> - -------------- <br /> BUILDING PERMIT ISSUED ----------------------------------- -----------------------------------DATE - ----------------------------------- - <br /> ADDITIONAL C MENT ---- ----- -------------------- - --- ------ ------- -I-----------------=-- <br /> j t-- {/ <br /> ---------- fit( Fyt ------ - - ---- ��i+u'r �� <br /> / ------ - ----- ---- t <br /> ---------- --------------- <br /> Final Inspection by. -------- - { ,-- ------------------------------------ ---------------- -------------Date .-- r� <br /> NAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />