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FOR OFFICE USE: V\ APPLICATION FOR SANITATION PERMIT <br /> - Permit No. .-1Ct'/= y <br /> --------------- <br /> (Complete in Triplicate) <br /> ' <br /> Date Issued <br /> if 4 r- This permit Expires ! Year From 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. 549 and existing Rules and Regul tions: <br /> Y <br /> C� <br /> /r• ' • <br /> ,� NSUS TRACT --__-_-- _, •-------...__ <br /> JOB ADDRESS/LOCATIONcQ /-_ <br /> Own iY Phone <br /> �7 fel <br /> Addressf�P__C?. r 'l f1 �1 ?--------------------------- City / <br /> s <br /> Contractor's Name /)/--S'A�rC---�-1��---�� ---=-------.License #moi. j�` -- Phon ------------------------------- <br /> Installation <br /> -3 - <br /> Installation will serve: Residence �artment House❑ Commercial [-]Trailer Court l❑ <br /> ,r <br /> Motel ❑Other - ------- - ---------------- --------•- <br /> Number of living units:-.. ------ Number of bedrooms - ------Garba_ge Grinder -___ Lot Size ------------ <br /> 1 Private <br /> Wa#er Supply: Public System and name -------------------------------•----------------------------------------------------------•--------------- <br /> Character of soil to a depth of 3 feet: Sand Silfi❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe,F Fill Material -No---- If yes, type __.-____.__________________ <br /> I I <br /> (PlotIpIan, showing size of lot, location of system in 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 200 feet,) <br /> p If <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[4__1 --- <br /> Size-- --------------------- -- ---------- ------ Liquid Depth _ _-----------------• ---- <br /> Ca acit driv __ T e _JW---- MateriaO No Compartments ......... <br /> ---- <br /> P YI - -- -- YP r <br /> _..,. .istance_to nearest:�We11 - - -- -------------------Foundation,/10- ------. Pro}�.1ine�✓t 1,--------- <br /> �_ _ . <br /> LEACHING LINE [ No. of, Lines 'A------------------ Length of each line.- --�----=---------- Total Length ,;��_----��:---- <br /> `D' Box .-- Type Filter MaterialYt_�4f---------Depth Filter Material �l--Iff---------•--------------j- � <br /> Distance-to nearest: Well __ ______-_____ Foundation /0--------------- Property Line, 1�--_____--- <br /> ff } Rock Filled Yes No <br /> SEEPAGE P17 [: 1 Depth ---f.--------------- Diameter - Number ❑ <br /> Wafter )able Depth ------------------------------------------------Rock Size -------------------------------- <br /> ' ----. Prop. -- ---- <br /> Distance t� nearest: Well ----------------------------------------Foundation ---------__---- p• Line ------------- <br /> REPAIR/ADDITI ; (Prev. Sonitalioh Permit# -------- ----------------------------------- Date ----------------------------------1 <br /> ' ( { - <br /> SeP g tic Ta' ( PecifeCfe Reeulr�ts) <br /> Y q <br /> (• ments) ----_ l <br /> Disposal ielb (SP Y G ;z;. <br /> _._A------------ _ ._ - <br /> f - <br /> l <br /> i reverse S1de-------�;-"- ------- ---- <br /> -- ------ <br /> r (Draw existing and required addition on revs 1 <br /> 1'he hereby cern that l have prlpred this application and that the work will be done n accordance with San Joaquin <br /> Y _ �►i ; ,, <br /> County Ordinances, Stole Laws c nd Rules and Regulations of.the:San_Joaquin Llocal Health District. Home owner or,licen- <br /> t 1 ti 1 S � ��b— ,\ `---. -d .• t- 7n t`. s V- n,j i <br /> S" agents si6nciture certifies the following: , '� L' ,; <br /> "1 certify that in!the performan alof the work for which this permit is issued, -4 <br /> as <br /> not employ any person in such mgnner <br /> i ' s �.- <br /> as to becom subject to Workm nis Compens tion laws of California." <br /> Signa <br /> [ � . `' --------- ----------I--,-, <br /> TBY -------------------- <br /> (Iflother <br /> th era 1 ' <br /> l ---, FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY <br /> i <br /> BUILDING PERMIT ISSUED ----- ------ --------------------- -------------- DATE <br /> DATE ------ <br /> ADDITIONAL COMMEN+TA___ _ _- ____ ' <br /> � f----------- ------------------ -` { <br /> 5_____________________________--------------- <br /> ------------------------------- <br /> _______________ __ •-I-- <br /> _-______..___________________ __----------- __________- ---_____.____.___________ <br /> ___________________F <br /> i------- ---------- ----- - ------------------ - - ----- --- ;~- to <br /> Final Inspe ion by: -- ------------ --- --------------i------- `.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r �' <br />