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FOP, OFFICE use: t-k, i cc--o 11� u 1 frr /jt 'a44/ #14" s7//- <br /> �� Permit No: <br /> -r � �D <br /> APPLICATION FOR SANITATION PERMITt/ -r� <br /> ---------------------------- � r <br /> � {Complete in Triplicate} <br /> -- 7 <br /> ------ ------------------------ - <br /> �� Date Issued <br /> This Permit Expires I''Year From Date Issued <br /> Application is'Kereby made to the San Joaquin Local Health District for a permit to constructand 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/LOCATIONf�!?------------------------ ----------- ---------------CENSUS TRACT -------------------------- <br /> f " <br /> Owner's Name ; --- f ---------------- ------------------.-Phone ------------ -- ------------------- <br /> Address ------ -! 4re-e-,6,)04 <br /> '- -- City <br /> - <br /> (dLicense � Phone � aA -_Contractor's.Name -------�F°/ ' n� � ,w----- M i <br /> Installation will:serve: Residence oApartmerit House❑ Commercial : Trailer Court 0 - <br /> Motel ❑ Other ----------------------------------------- <br /> 7� <br /> 3 <br /> Number of living units:---/----- Number of bedrooms ----_---Garbage Grinder,0 Lot Size 4 .----:� ---�--arm---•- , <br /> Water Supply: Public System and name - f_ ------ --------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [❑ Adobe . Fill Material.N0---_ If yes, type --------------------------- i <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 /> PACKAGE TREATMENT [ ]' SEPTIC TANK' Size--- -g - ------------ <br /> -------- Liquid Depth - ------ <br /> c4acity.,/XAV- Type,��-ex-44 !"-------- <br /> Capacity..��� _---- TYpeP1"t"tes`�Q�__ Ma#erial��l1.�'/�,e'No. Compartments ---_--- <br /> Distance to nearest: Well ------- ^r"'--------------------Foundation --- - -------- Prap. Line - - =-------- ] <br /> - ; , .. <br /> LEACHING LINE,-, 'No."of Lines -----,.�--- ----------- Length of each line, � _�---.- --.- Total Length ` -------- <br /> 7E ,�y <br /> - <br /> 'D' Box _ Type Filter Material 1 -f��G epth Filter Material ,r��---_----_----- ......e........... <br /> Distance to nearest: Well ---" "'�'---_----- f=oundation ------- Property Line -- ------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> - Water Table Depth ------------------------------------------------Rock Size ---------------------- <br /> ------_...Foundation --- Prop. Line ---------------------- <br /> REPAIR/ADDITION <br /> -- - E <br /> Distance to nearest: Well ----------------------------- ---- --------•- - - + <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- <br /> Septic <br /> ----_---_-----------------------Septic Tank (Specify Requirements) ---------- -- ---------------------------------------------- ----------------------------- <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, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: ^' <br /> "1 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 /> Signed ------- ------------ <br /> ( -------Lam ----------------- -------------------- ------- Owner <br /> Title -----BY ------------- -------------------- ------- <br /> ; <br /> � <br /> f other than owner) <br /> f OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- e- 0 <br /> � --------------- <br /> ------------------- ------------------ -------------� DATE ---- �---------- - <br /> BUILDING .PERMIT ISSUED - ----------------- DATE <br /> a - ---- <br /> ADDITIONAL COMMENTS - --- ---- ---------- --------------------------- <br /> ------------------------------------------------------------------------------ <br /> -------------------------------------------- ------ -------------------------------------------------------------------------------------------------------------------------------------- <br /> --- �4_' <br /> Final Inspection by: ---------- .Date ------ ----d ----- ------------ ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />