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,......rte wrrn c %Fbt, .. <br /> APPLICATION FOR SANITATIONPEttNIIT <br /> (Complete In Triplicate) Permit No. .7 .-.s <br /> ......... ......................................... Date tquad -1 am <br /> ..... .. .. This Permit Expire`t 4 Year From Date Issued <br /> Application Is hereby evade to the San 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 Regulationss <br /> !08 ADDRESS/LOCATION ...�0�.. ?'�::�®.`...... ... ................................. CENSUS TRACT .......................... <br /> Owner's Name ............. ....�- .r�..a�`:.k1G1.:...... .._+ ... . . .......................................................Phone . .x..` 7 ..... <br /> Address .................... i f�i Q � 4.' ,...........................City ............. ... . ...................................... <br /> r - .,.license ..� T.: <br /> Contractor's Name '"�" ' ' '�J Z 3... Phone <br /> Installation will serve: Residence[1 Apartment House❑ Commercial-aTrailer Court ❑ <br /> i Motelf(3.Other................................. .... r '0 <br /> F <br /> Number of living units:.: --:--- Plumber of bedroogms ............Garbage Grinder ....__..._- Lot Size . _,.X_.� �...................0 <br /> Water Supply: Public System and ame .... .R..i........r....� tu .......... ......._.......---...........:....................ferivate ❑ (C, <br /> Character of soil to a depth of-3 feet: Sand❑ Silt Q —Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ V' <br /> i. Hardpan❑ Adobe Fill Materlal ............If yes,type............... ............ <br /> )Plot plan, showing size of-let,lotation of system In relation td-Wells, buildings, etc. must be plated on reverse side.) <br /> NEW INSTALLATION: (No septic tank ar seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK f j` ' Size..........................I..................... Liquid Depth .......................... <br /> F CapacityF......-----•----.... Type .................... Material;:.................. No. "Compartments ...................... <br /> ' Distance to nearest: Well ..Foundation <br /> �.: ;........._�.T _ pa Ire .................... <br /> . ........ Pro .. <br /> LEACHING LINE [ j No. of Lines ........................ length of each lute................... .... Total Length <br /> D. <br /> Box '!----------- Type Filter Materia! ...Depth Filter Material .... <br /> Distance-to-nearest, Well ... Foundation ........................ Property Line ....................... <br /> SEEP [ ) Depth ................. Diameter Number . Rock Filled Yea ❑ No Q <br /> Water Table Depth ----•----------•.............:......±..........Rock Size ............................... <br /> Distance to nearest, Wel! ......:...:.........Foundation .... Prop. Line <br /> REPAIR/ADDITION[Prov. Sanitation. Permit 54s .' ) <br /> ................•----.....----..,.._........ Date ...-----...._..,.....r....r...._ - <br /> , Septic Tank [Specify Requirements) ................... .... ......................... ....... ... ..................._.............................. <br /> Disposal Field (Specify Requirements) --•..---. .------....Z �. ... .il. .j� .............................................. <br /> - ............. . ':: .: ---• --. �.. .1�... .- .. .. .l._.-.. . ......................................... <br /> N .................................................. ....................... .... .. ................................... .....................•..........---..........._......... <br /> i (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 [Icon.-- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for whichthis-permit-Is issued, I shall not employ any person In such manlier <br /> as to become subject to Workman's Compensation laws of Colifornla." <br /> Signed .................. --------- ---- -, , .. ........---............ ... Owner . <br /> _ Title ............ <br /> ................... <br /> [if other t an nor} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By ...........Q" ....... DATC <br /> BUILDING PERMIT ISSUED ....................................... .............DATE <br /> ADDITIONAL COMMENTS <br /> ................................. ....................................................•..... ....... ............._......... <br /> .......................................................... ..:�:w:....... ... <br /> Final Inspection by:EH J� ..r. �� ..�............. <br /> 13 2!a 1--6F4 Rev. SAN JOAQUIN LOCAL HEaLT 8/7h 3M <br />