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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- Permit No.4�... <br /> - ------------ <br /> _. (Complete in Triplicate) <br /> --------- ----------------------------------- 4 <br /> - date Issued <br /> ' This Permit Expires 1 Year From Date lisued <br /> Application is hereby made to the San Joaquin Local Health Distract`for o permit to construct and install the work herein <br /> described. This application is made in compliance with County-Ordinnnee No'.-549 and existing Rules and Regulations. <br /> I <br /> - -_ ------- --- --JOB ADDRESS/ OCATIO_ ppZrq — � { P10.&/1I CENSUS TRACT J <br /> Owner's Name ---------- 1-Af------- <br /> ....... � Phone <br /> pl $ = <br /> i 1 J r <br /> Address ----------L l z'1--�---�=------ �I�-��--.--_=�D'--- -----------. GitY - --!'[- -�IP29 eV---------------------!---------- --------------------- <br /> Contractor's Name-960M. _ ____ <br /> -. :`.= ---------------------------L rinse # ------------------------ Phone --------=------------------- <br /> Installation will serve: Residence rt�partment House❑ Commercial iE Trailer Court C] <br /> Motel ❑Other -------------------------------- <br /> Number of living units------I_.__ Number of bedrooms .__-----Garbage Griner -A/O---- Private��___ tot Size _-�-__C:��4 <br /> - �-» <br /> Water Supply: ubl�ic System and name ------------- -----__------------------Id ------------ to n <br /> . Character of sail-to a depth of 3 feet: ,_ Sand❑ Silt❑ _Clay-❑ Pep ❑ Sandy Loam Clay Loam:❑ <br /> Hardpan ❑ Adobe ❑ Fill Materia _ { _ ifiyes, type ---------- ------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, Iduildings/etc. must be placed onreverseside.) <br /> i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> 1 <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size--------------------------------------------.___ Liquid Depth______ <br /> Capacity -------------------- Type ----- Material No. Compartments .- . =�;} <br /> Distance to nearest:---Well---- __ __:____ -------------`_-Foundation ______________ ____ Prop.-Line---_11_ ' ....... <br /> LEACHING LINE [ ] No, of Lines -------------- <br /> ------- --------- L y2jth of-each lint �__._______-------- Total Length r }} _ <br /> g <br /> 1 'D' Box -----------_ Type Filter Material _______ __�,i_Dpth Filter Material --------------------.------------••--------- <br /> Distance to nearestlWell -------------1---------- Foundation ?_____________________: Property Line ________________________ <br /> SEEPAGE PIT . De th -------- - --=-- ?are_ <br /> : Number ---------------------------- Rock Filled] Yes ❑ No .(3 <br /> Water Table Depth <br /> Rock Size f--------------- <br /> Distance to nearest: Well ------------------- _--f___-_Foundation ------------ --------- Prop. Line ---------------------- <br /> Qate4:: :� ''=t � <br /> REPAIR/ADDITION{Prev. Sanitation Permit# ---------------------------------------- --- _�� �------ ----- <br /> ----) <br /> Septic Tank (Specify Requirem nts .- i .IST34I_X.__..: -------------- <br /> Disposal Field {Specify Requirements) .. - 1R _ __ _G1/V- -------- -------- --� <br /> er-10--r-- YL-1�-----4-� f�rLA c J --------- <br /> -------- a ,� .t ----- � • <br /> -- -------- ----- <br /> (Draw existing and required addiiion on reverse side) W <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 /> "I certif that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as tat <br /> c e su ct to Workm 's Co ensati.on laws of California." <br /> } •' . <br /> Signe -- ---- --11_ G�sc m Owner <br /> ----------------------------------------------- <br /> ------------------ <br /> i (If other than owner) i <br /> 1' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ---------------`--------------------------- -----. DATE ----- <br /> BUILDING <br /> ---BUILDING PERMIT ISSUED --------- ----- ---------------------------=------------------�......------. DATE ------------- ----------------------------- <br /> --- - <br /> ADDlTION�AL C)N1NI NTS- „-_ _ . __._, 113 ------_-w�._.-,._... _ �- - _-.—._----_ .--------------------------_7 —- ------ ------ ----- r <br /> Cl -------------- <br /> ' 1 f-` ---- <br /> ------------------------------------- <br /> 4 ----=------------------------------- <br /> 1 -,---- ------------ -- ---- - ---------------- _---- <br /> --- - --- --- --- - -- -------- -------------------- <br /> Final Inspe ----•----------------- ------------ --------.Date ---- <br /> SAN <br /> --SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H..9 1-'b8 Rev. 5M <br />