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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> :......- ......................... t,...... Permit No. . �.2y� <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District fora 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 /> � c <br /> JOB ADDRESS/LOCd --- - -------- ---C ... ..............--------.....................CENSUS TRACT .... ........... <br /> Owner's Name .... P. .r...... ........ ...........................................Z- h�oAddress __,_... .f ..`3�, .... F...C�` '-`-�----- ----•--• ............. City - :- ...__........ ... ...... <br /> ( Contractors Nome .. <br /> icense # 1 Phone � . <br /> Installation will serve: Residence °Apartment House❑ Commercial ❑Trailer Court Q <br /> [ i Motel 0 Other ............ •.......................••.. <br /> Number of living units:.._.__ Number of b rooms .. __..::.Garbo a_grinder Lot Size ... s� ► .. .... ......... <br /> Water Supply. Public System and name .._ 'u_._ _ Private ❑ <br /> -- . .-._.....-•--•-•••--••••----•-- •........... .. <br /> Character of sail'to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam ❑ <br /> ^� Hardpan ❑ Adobe X 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 seepage pit permitted'if public sewer is available within 200 feet,} <br /> i PACKAGE TREATMENT [ ] SEPTIC TANK i ], f!Y 7 i�ze------------------------------------------------ Liquid Depth _.._... .............. <br /> CapacityType . Material______________________ No. Compartments .........­1 <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ._...... ............ <br /> LEACHING LINE j No. of Lines _.____. _ _._ F r Total Len ... .. <br /> _ �---..__.... Length of each 1'ne.----- - -. ..... .: Length �--..:._..--•-•-----. <br /> 'D' Box ...i7----- Type Filter Material _--_-.Depth Filter Material ._. .r._........................:... <br /> Distance to nearest: Well . ..�J........ oundation .11/ ........... <br /> ._- Property Line ........... <br /> SE'E'PAGE PIT Depthf, �____._ Diameter � . _�..r Number ..... ............ ...... Rack Filled Yes [ No Q <br /> 1 Water Table Depth ....... . ------------------------ .Rock Size .. '------- <br /> Distance to nearest: Well _C C,..........Foundation ,14 _.... Prop. Line ...sr— _--__--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -__•...................•---...._._.......... Date --•-- ----•------___-_.._.......) <br /> Septic Tank {Specify Requirements} ............... ......... --------------------------- -_ <br /> r' <br /> Disposal Field (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,' Ind Rules and Regulations of the San Joaquin Local Health District. Home owner or licew <br /> sed agents signature certifies the following: <br /> 1-1'A' that in the performance of the work far 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 /> Signed ----------- ......•-----------------------.._--- ----------- ------------- Owner <br /> 8y ...... ... .. - ----•------- ------- Title ..... � - __.:._....... ........ <br /> (ff oti�er than owner) U <br /> FOR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY . ..... .. . . .................................................... ...... DATE .. . <br /> BUILDING PERMIT ISSUED ....... ... DATE ...... .................................... <br /> ----------- - -- <br /> ADDITIONAL COMMENTS ..... ..... ..... . ::�.....-- --._...._._._--•-- ---- ..................... <br /> Z - •...: ... ---•.......................•---•-•.......-- <br /> --•-•-•....................................... -•-••----••-=-- ---- •---... --------------•-----------•--•----.-._..........-- ... <br /> Z <br /> ...........................................:.....•. ....... <br /> ............................:............f....� --------------------------------- <br /> ..--..................................... <br /> .._.. <br /> Final Inspection by: ......... == f ................................ <br /> Date ......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTM? <br /> ., .. <br /> s u 13 24 ,-,Au nes. 'nA► 7/723.,,4 <br />