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FOR OFFICE USE: _- <br /> APPLICATION ICOR SANITATION PERMIT <br /> ......................................................... Permit No. ...7...C-.:17,1 <br /> (Complete In Triplicate) <br /> N. ... <br /> ......................................................... This Permit Expires t Year from Date Issued <br /> Data Issued ._� ............ <br /> Application is hereby made to the Son 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 Regulotions: <br /> JOB ADDRESS/LOCATION �•,..,]_D! /� t �/�� <br /> . ..'.-.-,-....._�_ _�-.--- . .. ........................................CENSUS TRACT ._...._.............._.... <br /> Owner's Name �. /r � g. h1 �----•-------------•...----•-••_•--..........................----•-..Phone ............ --•-•-.........---- <br /> Address Q� �,,-1�� / �+_........ ..city `4 ��jp�i ...... <br /> Contractor's Name .... License.� / -.. , - License#/27.91- 3.3. Phone V, �. .. -- <br /> '. r. <br /> Installation will serve: Residence g Apartment Mouse 0 Commercial❑Traller Court 0 <br /> k <br /> Motel ❑Other <br /> ..... ............ <br /> Number of living units.-./------ Number of bedrooms ____._...Garbage Grinder'--1*- -P,t. Lot Site ....................... <br /> Water Supply: Public System and name ........................................................­ .-.._......................--•-- ............Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan❑ Adobes Fill Material !...........If yes,type ............... ............ <br /> (Piot 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................................................ Liquid Depth .............. <br /> Capacity ----------••..... Type ---� <br /> -- T ____.___._.:....._.. Material---------------------- .No. Compartments ................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...........:.......... <br /> � <br /> LEACHING LINE No. of <br /> { ] Lines ....- ..___.... Length of each line............................ Total Length ............................ <br /> V Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> � <br /> Distance to nearest: Well ........................ Foundation .........I——........... Property Line ..._......... .......— 6" <br /> SEEPAGE PIT [ } Depth -------------------- Diameter .....,-.......... Number -----------------• ....... Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ................................................Rock Size ..................•............. <br /> Distance to nearest: Well ..............Foundation ---------- .-- Prop. Line <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ..........................................•_ Date- .......:. .................... <br /> Septic Tank (Specify Requirements) �.......................... ... ....................•- •------ w._...,_...-.-................- _....•.....-..._-._ <br /> Disposal Field !Specify Requirements) --- .t.Cw�Crt^_... ..-- ----- <br /> - -- <br /> --------------- ----------------- ---•-------- -------•-- - -•••---- ----•----- --•••--•--• ... -------------•------•-- ---- ---------------•-- ---•------- <br /> ----- .------- <br /> -------------------.---�v...' --------T........1_r..... -3 ' 'S' ... � ' ...................... <br /> (Draw existing and required addition on ever4s€de) <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 Heal&District.. Home owner or Ilcen- <br /> sed agents signature certifies the following: <br /> "I 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 ------------------•- ---- - ---•--• - ............... <br /> ._...--- -..... Owner <br /> BY ----- -- ---- .. . - -- ---•- •...... litre -.__ � r '!7_Cf / ,. ......... .......... <br /> (if other th n owner! <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ..................__--._....•--•--...-----•-.-• _-- _ -. .._ ._ <br /> - - ........... .... PATE �.'�'�...' -• <br /> -?.- ------•-• -• <br /> BUILDING PERMIT ISSUED _.. •---••-.......................................DATE . --- ................................... <br /> ADDITIONAL COMMENTS ............................................ <br /> .........I--------- ------------------------------••-•-------------._._._. -------- ----------------- -----•-..__---......._..----..._.�_---------------------------. -----------.... .............. <br /> -------------- •-------------------- ------------------••-....- ;---------•—-•--------------•--•-----•-----•----------------------------- ........ -------....------------------ -------...---•-•---- <br /> --------------------------.••------_..._ <br /> ins Inspection by: ..- r ,.z_ Date ................. ......... .....•;•---- <br /> EH 13 2h 1-68 v. 5m SAN JOAQUIN JOCAL HEALTH DISTRICT $/7h 3M <br />