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r <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ....%.-..�_=� ....................... Permit No. ..7.,.3..-. .-z/7 ' <br /> (Complete in Triplicate) <br /> ...... This Permit Expires 1 Year From Date Issued Date Issued . �...�.1. <br /> .7.. <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the'work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 15,;M140 if.......:..... .-._.................CENSUS TRACT ..... <br /> ._:.................. <br /> Owner's Name .... ................. ..... .........................Phone .................................... <br /> Address .........., e117 ms......_ y <br /> --------------------------------------------------•-----....... cit 422 . . __ �....._........---............... ........... <br /> Contractor's Non)AP .................. ...................................License #�,/�.r�,��. Phone��i!Y�/�.... <br /> Installation will serve: Residence ZApartment House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other ................: <br /> Number of living units:.... Number of bedrooms ___�------Garbage Grinder / i .. Lot Size .1?1W7XJ 2W1................. <br /> Water Supply. Public System and name ...............-.........................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand D Silt❑, Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe X Fill Material ............ If yes,type ............................ � <br /> {Piot plan, showing size of Iof, Focation of sysiem in.-relation to wells, buildings, etc. must be placed on reverse side.} <br /> NEW.INSTALLATION: (No septic lank or seepage pita permitted if public seWe'r is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TAMC[ ] Size................................. .. Liquid Depth .......................... <br /> w; Capacity .. -- ¢YPe t. + _ • ...................... �1 <br /> ,y ...... --•--- •-:?-----_-_--- -•-- Material---•------------------ No. Compartments <br /> Distance'to"nearest: Well -- ..........1.-r-..........Foundation ..................... Prop. Line ...................... <br /> LEACHING LINE ,'{ ] No. of Lines•--------------- ------- -lAngth ofeach line........_...--------... <br /> ..... Total Length <br /> 'D' Box Type Filter Material <br /> 4 <br /> ------------ ------------•-----..Depth Filter Material ---•----._...-•.--•......................... <br /> ' Distance to'nearest: Well ........................'Foundation Property Line ........................ <br /> SEEP�� [ ] Depth .............. Diameter ............... Number ............................ Rock.Filled Yes ❑ No Q �d <br /> r. Water Table Depth <br /> ............Rock Size "y3 <br /> " Distdince to nearest: Well ..........................t.............Foundation .---•----........... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _..._.._.................................... Date .................................. <br /> Septic To�k (Specify Requirements) ..................•--6...................�;..................--•-•----------•----------. .._....._a.....w...... -----------...--- <br /> Disposal,. Field (Specify Requirements) --.��-.f�GG_------a ---. � :�1,P % - , .......--•-•......... <br /> .--Y./If/111r------...-'------------------------------------------------------------------------------------------------------- <br /> •------------------{.:......----..-------------- ------- .......... ..... -•--------- ...........----------------------------------------------.............-------------•---- <br /> (Draw existing and required addition on reverse side) <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 Health DistriFt. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this perniit"is iisuid;i sholl'not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." E <br /> Signed ......... ...... .. ................ Owner <br /> *� --- Title , <br /> (If-- er than owner) <br /> O`R OEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..... ----- ....... ...........................................--•-•-•--._.. DATE _. ...EP...- _...._.... <br /> BUILDING PERMIT ISSUED DATE <br /> ADDITIONALCOMMI`cf�7TS' ..........................Y............................................. .............................................................................. <br /> ........................................_......------...------•--•---------------------------------_--••-•---------........._.....-----•------............._........ ................................ <br /> ------------•--•-------•....................... . ...... . ........................................................_.............................._.---........_ ......._...._.....__. <br /> Final Inspection by: - -----.Date ..? lli•�•_. ............ <br /> SAN..JOAQUIN LOCAL HEALTH DISTRICT tt/W <br /> r <br /> E. H.13 24 1.'68 Rev. 5M 7/723 ,1 <br />