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.vm yrrIN.G VdG <br /> APPLICATION FOR SANITATION PERMIT <br /> .............................................. <br /> Permit No. ..................... <br /> (Complete In Triplicate) <br /> 7-1127 74 <br /> This Permit Expires 4 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 com (sane with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._..-..f �. ."..-9.j.�-- ............. ....... ......................CENSUS TRACT .......................... <br /> Owner's Name .-......... 'i2� 1 .. .. ............................................... ..Phone .Q Zit7...._.. <br /> SO <br /> Fiddress ............."...............1 . ... ....... _.......••.........City .................... ..----••...........-. ...... <br /> Contractor's Name ............. ....... SU c!�...--..................---License# � �i� ... Phone -----•- <br /> !nstallation will serve: Residence(Apartment House Commercial❑Trallw Court ❑ <br /> Motel ❑Other <br /> Number of living units ......f--- Number of bedrooms ......J...Garbage Grinder ............ Lot Size .................. <br /> Water Supply. Public System and name . ...................•-•--•--•-----•---...-----........_.------.....------.........._..........----•-----•..Private ❑ <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam (3 Clay Loam ❑ <br /> Hardpan ® Adobe Fill Materlal ............If yet,type............... ............ W <br /> Mlot 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK f I Size................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments .................... <br /> Distance to nearest: Well .Foundation . Prop. Line <br /> '-EACHING LINE ( No. of Lines ........................ Length of each line....................... Total Length ........................... <br /> `D' Box ............ Type Filter Material ....................Depth Filter Material ........................................... <br /> - , Distance to nearest: Well ........................ Foundation ........................ Property Line ....................... <br /> SEEPAGE ( ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ..--•-•--------•..........................••--..Rock Size ................................ <br /> Distance to nearest: Well ............Foundation .... Prop. Line <br /> REPAIR/ADDITION IPrev. Sanitation Permit# .........................I.................. Date ..................................� <br /> Septic Tank (Specify Requirementsl ,................ <br /> .. ........................................................ <br /> .�:K�. ...... ...... ............................................................... <br /> Disoosal Field (Specify Requirements) .. ....................................:.................... <br /> -•--------••`Y.--- X. ............................................................................. <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 wish San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Hone owner or Ilcen- <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 /> a-anee ---------------------- •.. ........ Owner <br /> 3y ..... . ........................................ Title ...........-�c�.. ............................................ <br /> 40othan owned <br /> j DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... .--.-.-...--.............................I.............---.........D. A...T. <br /> ATE ..... 6.:..........•.... <br /> BUILDINGPERMIT ISSUED ....... .. . ...... ......::......---.................-..........----------- ....DATE>.......................................... <br /> ADDITIONALCOMMENTS ...... ... --......................................."..---....".............."................................. <br /> ........ ........... .......... .................................•-- - ....:......".""... ......... <br /> ..... .......... . ........... ........... .' .............................. <br /> Final inspection by: . r -� ........ ............................. ... ...... .�.. <br /> 3 2!t 1`613 1 v. M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />