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FOUR OFFICE USE. <br /> f . r APPLICATION FOR SANITATION PERMIT <br /> :........................... . "".`..`-. ICo-mplete in Trlpllea%) Permit No. <br /> F• <br /> .... This Permit Expires i Year from Date Issued Date (slued ..........:...... <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-7. s made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRi: I` P� <br /> SS/LOC®ATION. a ®._.._.. .. .f: .,.� �..... � r....CENSUS TRACT <br />` Owner's Name <br /> ,..... ...........Phone . <br /> Q ?a. .City r-�a . �...._ <br /> Address .. .................... <br /> a <br /> Contractor's Name ---..:��----------••----------------------------------------------------=--------License #_4 z�.._�Z. Phone ....... 67 <br /> Installation will serve: ResidenceXApartrment House Commercial ]Trailer Court E] <br /> - <br /> Motel 0 Other <br /> Number of living units:_..--- -... Number of bedrooms ....:......Garbage Grinder ....... Lot sin ........................................_--- <br /> Water Supply: Public System and name <br /> ....................... <br /> .--.....__....-----•---•:••.._._..................................................Private Q. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o Cloy ❑ Peot O Sandy Loam O Clay Loam Q . <br /> r-Hardpan 0 Adobe 0 Fill Mctterlai ............if yes,type............... ............ <br /> 0 <br /> (Plot plan, showing siza of lot, location of system €n 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 2004eet,) <br /> CO <br /> PACKAGE TREATMENT SEPTIC TANK <br /> �: �x� 1/ . ._-.-._•- ----- Liquid pepth <br /> ��" Capacity ----------- Type -----_-_---...__ Material...................... No."Compartments ....................... <br /> Distance. to neo est: Well ..................................:.Foundation --------.............. Prop. Line ...................... <br /> LEACHING LINE ( J No: of Lines ..-------------------_ Length of each line....._..-_..............__-- Total. Length ............................ <br /> J70`0 At4w, <br /> `D'I Box ......------ Type Filter Material .............. .....Depth Filter Material <br /> __............f. <br /> Distance to nearest: Well ........................ Foundation ---.--........._._.:.... Property Line ... . .. ._ - <br /> [ ) Depth -------------------- Diameter ............... . Number ........ ------------------- Rock Filled Yes p No Q � <br /> WCTM ater Table Depths Rock Size <br /> I'x D )( �0 Distance to nearest: Well ....... -••---....m ........... ..rF n ........ rep. Line ••------ <br /> oundatio P i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _ .............. pate _ <br /> Septic Tank (Specify Requirements) -_. <br /> ...._ ....... <br /> Disposal Field (Specify Requirements) ------_-•. :- �._. -.fi <br /> , s <br /> Y -- - � ....... <br /> •---..... ---•--.. <br /> 9-7w.. ............... <br /> -----••------------- .I <br /> ' (Draw existing and required addition on reverse side{ �- <br /> I hereby certify that I have prepared this application and that the work will be dor+e in accordance with San Joaquin <br /> - <br /> County Ordinances, State La .Laws, and Rules andRegulations of the San .Joaquin local Health:District. Home owner or Mew <br /> sed agents signature certifies the following: ,- <br /> "I certify that in the perfornt!once of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to W r mall's m ensation-laws of California." <br /> 1./}(}�� p <br /> -- - <br /> Signed �� ---------------- -----_---------_-._ Owner <br /> By ----....--- �� <br /> �_ �� =. <br /> ..................... Title _...._._. .. -- �.. ---•-•---• -------...__.__......--••-•------•------- <br /> {If other than 'Owner) <br /> _. ,�- FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY ____--- -;---• DATE _._ -_ = <br /> BUILDING PERMIT ISSUED -9.... --------- --------------..-... -•------••- ....-•-- --------- ---------------DATE <br /> ADDITIONALCOMMENTS �I.._.. ------- -----------•--. ........-.........-----------..----------..-....._........_.-------------------------•-------•------ <br /> �I <br /> --------------- <br /> __ <br /> ............................_._.....__,il - <br /> ---- - ----- -- -......------------------------- <br /> Final Inspection by: ..- ------ - <br /> Date -�_.._. _. <br /> �I -- - r / ---..._••--- <br /> 13 2t� -bli R.V. m SAN JC>AQLIi LOCAL HEALTH DISTRICT 8/7h 3M <br />