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4 FOR OFFICE USE. <br /> ... APPLICATION ICOR SANITATION PERMIT <br /> ICamplete In Triplicate) Permit No. . -:7 .. <br /> ................. ......... .........--- <br /> This Permit Expires 1 Year From Date Issued <br /> 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. 5+49 and existing Rules and Regulations, <br /> 2 <br /> JOB ADQRI:SS/LOCAThONA`q1 8.._..1`.�f <br /> *.e.4X......t`"'.'.......... ......... ..... ......................CENSUS TRACT .....l.L. ................ <br /> Owner's Name ._.... •...r"cf� .54 <br /> - Rhone .`>` '. ?3......... <br /> Address <br /> .?.7.fr /�.�� .....-- city .. .................................... <br /> ` .. '..�� /... tl -� �r -96 .7.... <br /> Contractor's Name ................. . ............License : , ..... Phone <br /> Installation will serve: Residence Apartment House C) Commercial❑Trailer Court <br /> Mates ❑Other ......................................... f <br /> Number of living units.--...(..... Number of bedrooms .....Garbage Grinder ............ Lot Size ....c�� Z.. .......... <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�ff Fill Material ............ If yes,type ............... ............ <br /> {Plot pian, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: JNo septic taAk br seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size........................ . Liquid Depth <br /> Capacity .. No. Compartments <br /> P tY ---------------•-••- Type -----•-............. Material-----...--.......... ...................... Vf <br /> Distance to nearest: Well ...................... ...........Foundation ...................... Prop. Line ...................... J <br /> 00 <br /> LEACHING LINE [ ] No. of Lines ------------------------ lengthof each line............................ Total Length ..................:.......... <br /> 'D' Box ............ Type Filter Material ...................:Depth .Filter Material ............................................J" <br /> Distance to nearest; Well ........................ Foundation ........ ............... Property Line ........................ 0 r <br /> SEEPAGE PIT Lf <br /> [ ) Depth .-......-:-- <br /> Diameter .....--•..----- Number ... ........................ Rock Filled Yes ❑ No (:1 <br /> Water Table Depth .........Rock Size . <br /> Distance to nearest: Well -----•................•-------------....Foundation .................... Prop. Line ...................... <br /> REPAIR/At)DITION(Prev. Sanitation Permit# ..................--.------_---- --.--- Date ..................................1 <br /> Septic Tank #Specify Requirements) ............... �.: .... . ---- ---- ----­-­----------- <br /> ' <br /> . .. ........... .. ..... .............•----..... <br /> R�X <br /> Disposal Field (Specify Requirements) . �.� ( .........:----•....................................... <br /> --------------- ------------------------­-­---------------- - -----------------••------- ------•----- --. .. .. .............................................................. <br /> - <br /> (Draw existing and required addition on reverse sidel <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin y. <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.District. Hance owner or licen- <br /> sed agents signature certifies tits 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 ------------ -•-------- ------ ,' ��,, Owner <br /> 6 <br /> By ---- •-----... .. L_/ "'•--------------------------------------- Title f�. �..........---..-... <br /> (If oche han owner) <br /> FOR DIEPARTmEW uSE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------- IM............ DATE ..-.L-_ $:7?.....------------.._..-: <br /> BUILDING PERMIT ISSUED -----------------------------------------••-- <br /> - -------•---• •---- -------t ----.----------------DATE ....... -.----------.......--•• ---------- <br /> ADDITIONAL COMMENTS <br /> ----------------------------------------- ------•---- ---------••-• ---------------•....----. ---- <br /> Fina Inspection by: .-..:- ...... .......................... <br /> -...--....Date .. -�.7--- ----------------- <br /> -- <br /> 13 22t 1-6 } SAN JOAQUIN LOCAL HEALTH STRICT 8/7h 3M <br /> t <br />