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FOR OFFICE USE: i <br /> APPLICATION FOR SANITATION PERMIT // L <br /> ............. .... Permit No. <br /> • (Complete in Triplicate) <br /> ......................I....... <br /> ,.......... <br /> IN` Date Issued ..W"xf� <br /> _:.741 <br /> . ....... ................ This Permit Expires 1 Year From Date Issued <br />—Application-WRereby 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 /> J013 ADDRESS/LOCATION Y { <br /> f JAB .-_ .... .. ........................................................CENSUS TRACT ..............:...... <br /> ..:... <br /> Owner's Name .._ ._.. .- ' 1 t Phone ...................... <br /> Address .. ��..� . ...._... .. ------ City .....__ <br /> . _...._.. •----•--- <br /> Contractor's Name ....... f- - ------- --------------74-i—. .If. :.....License # /1M3 2---Phone .............................. <br /> Installation will serve: Residence portment House Commercial❑Trailer Court <br /> Motel ❑Other ............:............................... <br /> Number of living units------.___.. Number of bedrooms .-.....Garbage Grinder ...... Lot Size ............................................ <br /> Water Supply: Public System and name ............. .........................Private ®_ <br /> Character of soil to a depth of 3 feet: Sand nilt❑ Clay C] Peat E] Sandy Loam [I Clay Loam n <br /> Hardpan Adobe❑ Fill Material -------- ... If yes, type ............................ <br /> (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION; (No septic tank or seep' a pit permitted if p blic sewer is.available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK• Size- ! <br /> [ � 1 - ...X�7�_ _ Liquid Depth .. .. <br /> Capacity l ad?. A-_ Typ ------- -- ----- Material.. No. Compartments ............. . ! <br /> Distance to ne rest: Well ..... ......................Foundation .•4�.............. Prop. line <br /> LEACHING LINE [ j No, of Lines ..-. ........ len g t of each line; <br /> 'D' Box ...---_:_--- Type Filter Material ......--•--•-•------Deptr Q <br /> .Filter Material...........:................•-- ..._..-•__-- <br /> Distance to nearest: Well .......... Foundation - Za---11 ...... Property Line 4 ..--- •--.....:.;. m <br /> 'y 3 Number .:._...-_ 2........ Rock Filled Yes No <br /> SEEPAGE PIT [� Depth .. ................ Diameter <br /> Water Table .Depth .. �a Rork Size 1. ... .... ...... <br /> ---•- <br /> Distance to nearest: Well ..... �-�sp� _____________Foundation .lam .. _:...... Prop. Line_._ _. _...._... e <br /> G <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ... ... ..Date•_.,.................::.. ) <br /> Cf, c <br /> SepticTank (Specify Requirements) ......................................--------------------------------------------- ------......_...--•----_.._.....__..................... <br /> Disposal Field (Specify Requirements) -----_--------- -----S._..--_--._:..._...---------------------------------•----------------------- --•--•-- ...... I <br /> ---------------------------• -----•----•-...........-_....._._---------- ................................... <br /> ------------------------------------------•-----•---...­­­...........1-1------------------------------I---------I...... ---------------------------------------------.............._............... <br /> ... <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 done in accordance with San Joaquin <br />` County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or [icon- <br /> sed agents signature certifies the 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 Workm 's Compensation laws of California." <br /> Signed ................ ............... . ..... ... .... .... .- Owner <br /> --.... Title . . . _. .._: ,ri ........................ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY j <br /> 4 APPLICATION ACCEPTED BY .-- .-...--•................••••---- ---------- ---------------- ........... DATE .... <br /> .. _... ......�...7. _............... <br /> BUILDING PERMIT ISSUED ........ .......... ......------ ...... DATE ... .. ..... <br /> ADDITIONAL COMMENTS ..7f---- •' s:/. ... ,._ :_ .trrarrll�?� <br /> ............................•--........... _ '�.. <br /> ...-----••-•---••---•-------------------r..--•-------=••--- -- -------•------•-......_.....--•--- <br /> . .......................... <br /> Final Inspection by .. ...................................Date....._„ Q ......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/793 M i <br />