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FOR OFFICE USE: # <br /> N PERMIT <br /> APPLICATION FOR SANITATIO <br /> ----- -- Permit No. - f <br /> (Complete in Triplicate) <br /> ------ -------------------------------------------------- <br /> iv. Date Issued --- <br /> -- ------------------------------- This Permit Expires 1 Year From 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA' ON -- r....... 09(�PUL------ ' ---------------------CENSUS TRACT <br /> Y <br /> Owner's Name LZ(_ {�' e`----- NaD_11_ A9 ------------------------------------------------ <br /> Phone -,5 --'4D_��-- -•- <br /> Address ---- --#pp <br /> �_0-- ���� � = - ---------------'---------------------• City ---hi 1v-fj---`-- <br /> --------------- <br /> ------------------------------ <br /> Contractor's Name - -----_ License # ------------------- <br /> Phone <br /> as, NODEsT0 <br /> Installation will serve: Residence ❑r ApartmentH ❑ <br /> Commercial:❑Trailer Court l❑ <br /> MotelOther -------------------------------------- <br /> Number of living units:...6----- Number of bedrooms __tom------Garbage Grinder -I�-- Lot Size _ACR6-�-------------- <br /> Water Supply: Public System and name-.--__AT_F _t\------�t-- ------i. AT—'. �---------------•----------------Private E]w, i <br /> Character of soil to a depth of 3 feet: 56ridX Silt❑ Clay .❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material )V4)._ If yes, type ---------------------------- <br /> (Pilot <br /> ___-------- ------(Pilot plan, showing size of lot, location of:system in relations 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-------------------------------- --------------- Liquid Depth ---------------------=---- <br /> E Capacity --------- ------ Ty -------------------- Material-------------- ------- No. Compartments ----------------- <br /> Distance to nearest: Well _---- _______ '-_______________Foundati n ---__________________ Prop. Line __-_____.-__-_______. t <br /> - Length of each line_____________ ____________ Total Length _______.-_ <br /> LEACHING LINE [ ] No. of Lines __i8 r ; g <br /> 'D' Box - --------- Filte Mater,'ial _-_________________Depth Filter Material ____--_-_______-----_--------_.------------ <br /> a e . <br /> 1 n` <br /> Distance to nearest: Well c___._________ Foundation _______ ________________ Property Line -------------........... <br /> SEEPAGE PIT [ ] Depth uDiam ter '__a'___________ Number -------- -- _ ❑ <br /> --------------- --------------- Rock Filled Yes o <br /> -Water—Table DeptFi�.;.'-- = = =-----------Rock Siz -------------------------------- <br /> Distance to nearest: Wel.l----ell <br /> n ------_------------- Prop. Line ------------------__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#-________ ____________-------________. Date _ �___ ______.._________..____-) <br /> Septic Tank (Specify Requirements) ----`: =w--------------------------------------------------------- ------------- ------------------------ .---------------------------- <br /> Disposal Field (Specify Requirements) <br /> - -f IFI��P-per - L /1I {�i9-----------(� LixC�- <br /> 1�_4_ST(- =_---GI aJ cf-'- f > 1. --- X_ITI + LI- - _ . <br /> -i <br /> (Drawexisting 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 /> w <br /> County Ordinances, State Las, and:Rules-and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents si nature certifies the following: <br /> "I certify h t in the o manc f 'the work for which permit is issued; I shall not employ any person in such manner <br /> as to bec a subjec o. rkm Compensation laws of alifornia." <br /> Sign - - °�_ __'Owner <br /> ---- _ - ' <br /> i�y t <br /> Ti#le-------------------- <br /> (If other than owner) <br /> -p; FOR DEPARTMENT,U$E ONLY <br /> APPLICATION ACCEPTED-BY-i------�- iR,! -- -------------------------------------------------- DATE -- 3 <br /> BUILDINGPERMIT ISSUED ----------- ------------- ----------------------------------------------- -----------------=----------- --DATE ------------------------------------------- <br /> ITIONAI"CONINIENTS - = _ - -- - = = -------- <br /> ADD <br /> --------- -------- ------ ------ . _ ---- _---------------------------------------------------------------- <br /> - ---- _-- -- -- - <br /> -- <br /> -- <br /> ---------------------------------------- ----- _ - 9 ---- -------- <br /> ._...._ .. T... . .._ -----. _ -- -. T _ . . <br /> ----- <br /> --------------- - -(_ <br /> ---- ----- -- <br /> Final Inspection �``.1 ----- - Dafie - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M / - <br />