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FOR OFFICE USE: <br /> .' APPLICATION FOR SANITATION PERMIT <br /> ....................... ... {Complete in Triplicate) Permit No. ..7Lel-.7 S <br /> This Permit Expires I Year From bate Issued Date Issued <br /> t <br /> i 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. 54 and existing Rules and Regulations: <br /> s qy <br /> JOB ADDRESS/LOCATION .._.. ��a�i p <br /> ' Owner's Name - _ y- e CSUS TRACT..................._...... <br /> } .Phone e6&V �' <br /> Address -----•-....__ � ..._ __...._ <br /> ' ..... ... ... <br /> ..................City <br /> Contractor's Name . �.. ..._... <br /> - -. ------•---- License #�..'Z�.Z l Phone <br /> r Installation will serve: Residence ❑ partment House 1❑ Commercial'❑Trailer Court 0 <br /> f v .... <br /> f Motel ❑Other —........ <br /> t Number of living units_____________ Number of bedr000m$ .. ...Garbo a Grinder .__.___ .... Lot SizeQ-." ' / <br /> gF <br /> Supply, 0 . <br /> Water Su I Public System and name -----•--._.__-_—i t . <br /> Character of soil to a depth of 3 feet: Sand❑ Silt -Clay Private [] (AX❑ Y Peat 0 Sandy Loam 0 Clay loam ❑ - <br /> Hardpan 0 Adobe 0 Fill Material __:__..__--_ If es, <br /> = Y type ------- <br /> ­------------------ <br /> (Plot <br /> ••------ <br /> h � I <br /> (Piot plan, showing size of`lot, location of. system in relation .to wens, buildings, etc, must be placed on reverse side. I <br /> NEW on <br /> {No septic .tank or seepage pit permitted if public sewer is available within 200 feet,] ' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK i <br /> 3 Size__ ...._•..._... Liquid Depth <br /> Z . ... <br /> Capacity .._. .._..... <br /> �Ype ..------••------.... Material.._...---.:..:---•.._. No. Compartments <br /> = { <br /> Length of Foundation .......... <br /> ........ prop. Line .................... <br /> Distance to nearest: Well:_..._....._ <br /> LEACHING LINE [ ] No. of Lines _....--__ -- eoch line------••----------- -- <br /> ..... Total Length <br /> ........................: <br /> D' Box ............ Type Filter.Material .------••--- ....Depth Filter Material ........................................ <br /> Distance to nearest: Well ........................ Foundation ..........:..__._. _.... Property Line <br /> SEEPAGE PIT ---......... <br /> �^ [ j Depth -- Diameter :-------_.--_-- Number ---------------------------- Rock Filled Yes ❑ No C3 <br /> Water Table Depth { <br /> `''• -•------•-..._.__. .............Rock Size <br /> Distance to nearest: Well . --••- Foundation ....------•.. Prop. Line ----------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit # .... <br /> ....-•---------------------•-- -••--• Date <br /> Septic Tank (Specify Requirements) ------------------------ ' <br /> Disposal Field (Specify Requirements <br /> ��}rr °Al <br /> 1 . <br /> fi <br /> _...---• -• •- - - . <br /> g qe's'i'........................................................... <br /> (Draw existin and re aired addition on reverse side) •-••- <br /> I hereby certify that I have prepared this application and that the work well be done in accordance with San Joactyin <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 certify that in the performance of the <br /> 'yiro ii for which this permit is issued, I shall not em to 1F <br /> as to become subject to Workman's Compensation laws of California." ploy any person in such inanner <br /> Signed <br /> .. <br /> - -- -1...... <br /> -----• - _ Owner <br /> By �r . <br /> {If other than ow rl - Title _.: _ <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B <br /> BUILDING PERMIT ISSUED . - ....y :::.... _....•--------------- •--•----• DATE .lr1_.zl. ?.+�.._..._.,.. <br /> =:.......DATE <br /> ADDITIONAL COMMENTS :...... _ <br /> ...................................... _.._ - _.. .....-. <br /> Final inspection by: •-•--- .................... l <br /> ............. Date Gam._._.... <br /> JOAQUIN.:LOL <br /> L HEALTH DISTRICT ' <br /> . . -. ._ w <br /> l3 24 <br />