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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ...................___............... Permit No. .._ 'r--"Z .. <br /> 7 (Complete in Triplicate) <br /> ......................................................... <br /> This Permit Expires 1 Year From Date issued Date Issued ..���'...ry... <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. 544 and existing Rules and Regulations: <br /> JOB ADDI?ESS%LOCATION .--. aj:�:L _... .. Qn � - . = - CENSUS-TRACY .: .::... .".....:..:.,. ' �. <br /> t�'�u-....._._ <br /> Owner's Name ......� a -------------- ---.Phone ..............................•-----• <br /> Address . iG7 ...�. . _:. -.... . ....... CityP . .... ....,,. ... . <br /> a , <br /> Contractor's Name _044Z carr �` -_--.-- -- --------------- - ---License # -1� Phone ...._...__. .................. <br /> Installation will serve: Residence Apartment House C] Commercial ❑Trailer Court ❑ <br /> Motel (] Other ...-...,............L ..----••- <br /> Number of living units:...1,- ._... Number of bedrooms -__-Garbage Grinder ..... Lot Size _._. ...... <br /> Water Supply: Public System and name ..._............................... ....... : ----------------------_-----------------------------------Private [� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat,[] Sandy Loam [ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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/ <br /> sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK !'j/ Size--1 ��__.. _.._ Liquid Depth . .......... <br /> Capacity I.p-eZv .7a Type _A.L1- _ Material_r ?- ...... No. Compartments - .-----........ <br /> � <br /> I Distance to nearest: Well ... 1.Vie?. '.� :......__Foundation A.Q. -......- Prop. Line _xSr .. ----- <br /> LEACHING LINE [� No. of Lines - Length of each line Total Length _J.,;2LU?_ .............. <br /> 'D' Box ....1. Type Filter Material Depth Filter Material ....I-el.. .............................. <br /> Distance to nearest: Well --....J_b.p__ _ Foundation !_. _ - Property Line .._. ..._..._ <br /> SEEPAGE PIT [A,- Depth Diameter Number , ........... <br /> ..__.Rock Filled Yes No i❑ <br /> Water Table Depth .. 1. C�_- ' - r <br /> --..._ - ......Rock Size _...1._ � . .. ..-.... <br /> Distance to nearest: Well _.._.]_.6:e� ,_,,,.__'. ..._Foundation _...�-n- - ---.... Prop. line ._...'r........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit.# .._ --= ......... _.. °..___ ©ate____.._.................................. <br /> Septic Tank (Specify Requirementsy .... . .. '• -------------------•----.......--- ----. -- -- ------- <br /> ......._------ <br /> Disposal Field (Specify kequirements) --------------------- ------ -------------- <br /> ------------ <br /> _.... ----- -- ---------------- --------'- ---------------------------.---------- .. <br /> (Draw existing and required addition on reverse side) <br /> 1 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 at licen• <br /> sed agents signature certifies the following- <br /> "[ certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _:_. . .. - Owner <br /> ........ .... ------------------ <br /> 'v .. ............ <br /> n _ <br /> BY,, .. _ . ... . .......th...... <br /> (If other an owner[ Title `----- .. ..... <br /> FOR PEPARTMENT USE ONLY ---- <br /> APPLICATION ACCEPTED BY ...._jr-._. _ ..- - DATE ._/_ !.- ........................ <br /> BUILDING PERMIT ISSUED ,--...... ...............-..............................DATE . .....-.................................... <br /> ADDITIONALCOMMENTS ........................ .............-....... ............ ----------------- ......... ----------------.---------- ---------­-..._.-------- <br /> ----------- ................_.... --- -------------------- .........---------------- ----------------- <br /> -------------------- -------...- -�v .... -- --- ----------- <br /> Final Inspection by. ....._E�'. . .. .--- ......... ---•------ ............... .......... Date <br /> SAN JOAQUIN LOCAL. HEALTH„DISTRICT <br /> F E. H. 1-3 241-'68 Rev. 5M .7/723M- <br />