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f � FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. .7zl/.�J --- <br /> ...• ................... This Permit Expires 1 Year From Date Issued Date Issued -.y--��.7y. <br /> Application is hereby mto rl� Joaquin Local Hedith District for a permit to construct and install the work herein <br /> described T is a t' t made in compliance Wi h Coun Ordinance No. 5d9 and existing Rules and Regulations: <br /> J B ADDRESS/LOCA7�j O .4`... _ �..� 10 <br /> CENSUS TRACT .......................... <br /> Owner's Name ...... • . .:...v i _...... -....Phone .. ' <br /> Address s_.Q..f. 4, 4+- <br /> -Q--- <br /> Gt ;i',ca <br /> Contractor's Name 1..� ¢- .- - -0-- -e-Q---.License # � - <br /> -.- -------- -- - --- ... .... hone ....--•----•------------------ <br /> Installation will serve: Residence ❑Apartment House[] Commercial ❑Trailer Court C] <br /> f Motel ❑Other�0._J,� - --- <br /> k Number of living units: �_,.. Number of bedrooms -?LGarbage Grinder ............ Lot Size .................................. <br /> Water Supply: Public System and name .................. ..... <br /> • ........................�- -- -•---• ---------._....-•---•-------•�-------.....-•---•--Private <br /> Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> #Hardpan ❑ Adobe ❑ Fill Material . If yes, type ....................._----. <br /> (Plot plan, 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 see age pit permitted if p blit sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK Size} f <br /> Liquid Depth---.I/-. <br /> I Capacity J?—Pa Type Material.. =M <br /> _ _No. Compartments <br /> Distance to nearest: Well ' <br /> • -•--...�Gl�...... ..............Foundation ...`1r-'---......... Prop. line .......... <br /> EINE [ No. of Lines Length of each line. <br /> ............. <br /> LEACHING L .-�•...,�_:. . Len ....-. .d...�........ Total Length ....�cQ�. . <br /> 'D' Box .._. f.. . Type-Filter Material ......:�_R,_-.Depth Filter Material ..... 11................................ <br /> Distance to nearest: Well ............ 0.'.... Foundation .....Ap............ Property Line .- ...r.............. <br /> SEEPAGE PIT [ ) Depth ,... --------- Diameter ---------------- Number ...... ..............._..... Rock Filled Yes C] No-Q]1Water Table Depth ..:............._ -------------------------_---Rock Size ---• -----------------...,...... <br /> F _.. I <br /> Distance to nearest: Well .- ........................Foundation ..................... Prop. Line ...................... <br /> c <br /> REPAIR/ADDITION(Prey. Sanitation Permit# _._................. ------ Date .... -------------� <br /> Septic Tank {Specify Requirements) ...--- +-----------------------------•---- _............................. .........I..........---................ <br /> Disposal Field (Specify Requirements) ----------------------------------------------------___..............I...................---............ .................. j <br /> -------------------- ......--................ ------ --- ..- ............ ---- ..----- ------------....-----•-. ............. <br /> (Drciw 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 licen• f <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ....................... ------_------------- .• . -------._ Owner <br /> By . . . /L a G �. -o-L-12 . . --- .-.-.. Title . .. <br /> {If other than owner) u ............................... <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... .. .. -..... DATE .. .....:f .��:......... <br /> BUILDING PERMIT ISSUED .---..... .. ............... ... ..............DATE ..... ....... <br /> ADDITIONALCOMMENTS ........ -----------------------------_....-----------...----...------..............--•---......................................... <br /> .............................................. ---------------------------------...------------------------------ .................-..... ------ -.............--------------------------•---- <br /> ....._..........- _-------------------------------------•-----------........-----• . ............. .................... .....................................................-------•--..... . <br /> ............................................................. <br /> -------------------------------- <br /> FinalInspection by: ..-.... .- .. -•--------• ...-.................___......... •--------------Date . .............. -7--------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E <br /> E. H. 1-3 241.'AA Rav SM _ ' 7177 3 K <br />