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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> fPermit No. . ................ <br /> ]Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued ............ E. <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 mad in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRfSS/LOCATION .. ,r�.--.._....-\ CENSUS TRACT .:........................ <br /> Owner's Name . --•------•........ ....................................... . ....... ... ..Phone ........................... ........ <br /> -�. ------------------ ..................city <br /> Address __ f ................ ---- <br /> D� ��. ---- �� . ...... .. .-. ... . . <br /> Contractor's Name ------- --- ----�f1 ` ._- V 9 V. A.. `.2v` <br /> -•------- - ..................................License � �7-�---..... ...... Phone .. <br /> Installation will serve: Residence IRf Apartment House Commercial OTrailer Court 0 <br /> M Motel ❑Other--------------------------------------•-•-.- <br /> f <br /> Number of,living units:./ Number of bedrooms ..1 ..__Garbage Primdqr ............ Lot Size ..,1 .................................` y <br /> Water Supply: Public System and name ............. .....Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o Clay ❑ Peat❑ Sandy Loam o. Clay Loam ❑ <br /> Hardpan Adobe Fill Material ............ If yes,type ............... ............. <br /> I <br /> (Plot'plan, showing size of los, 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 />+ PACKAGE TREATMENT [ ] SEPTIC TANK UY, - S• e---- ,Z/.Z�kx' X_r�.............. Liquid Depth A/.................... <br /> . Capacity Type P/W_v�L---- .//-Ir � <br /> _ . <br /> __. No. Compartments •---o----------------- <br /> Distance. to nearest: Well ....e)-um-e/. ............Foundation j,Q_ ............ Prop. Line .Z1../C ' <br /> LEACHING LINE _ ✓ No. of Lines ....... — ' r .. - <br /> 1 [�I ...........:. Length of ea line... -..kms...__ Total Length -_-/26.---.._..__.. <br /> f� <br /> V.-Box --_ .. Type Filter <br /> rrM„,,ateriai,!_. .eAejeDepth .Filter Material ..C�........:.................�:! • <br /> ` <br /> Distance+to nearest: Well ....l.L ... Foundation ...Z0............. Property Line . . e... <br /> to JI <br /> SEEPAGE PIT [ ] Deptwc .... w ._ -.--- Number ......A---------------_ Rock Filled Yes No �[] <br /> s Water Table Depth ...... .............................Rock Size . ' <br /> Distance to nearest: Well-....= ...............Foundation .....6­0....... Prop. Line . .. <br /> REPAIR/ADDITION(Prev. Sanitation Permit'# --------------------------*................. Date .................................. <br /> Septic Tank (Specify Requirements)._._.. ...... ---••------------------------------------------ •-------•--- ................. .. ............ ---------- <br /> I - <br /> Disposal Field {Specify Requirements) ---------------- -••--------------.....--------------------------...:._... -------------------- ------------------------------------- . <br /> ------------------------------------------------ --------------------------------------.. .......................................... .............-------------------•..................... <br /> = <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 licew <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for "Wi this p er'mlt is Issued;1 shall not etn-la <br /> . p p y any person in such_manner <br /> as to beco s b' ct to W rkmanP <br /> •s Com ensation laws of California." <br /> Signed --• ------ ------- Owner <br /> BYTitle _.. .-------- -------------------------------------- <br /> (if other than owne <br /> FOS DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _... -- ll�ha--- ------------------------------------------------ DATE .. 5 ._ _.7�-------- - <br /> BUILDING PERMIT ISSUED -------- - -- ------ -- �/+ <br /> ADDITIONAL COMMENTS .. _._ ; � !�_- ._`: +-' yx..._ ” -'..._ ��^' <br /> :::: ---- --:_--------... ................. ::. - --------. . <br /> -- . - <br /> .......................... ..... --.. <br /> Final Inspection by: ---------•-•--------------- - _ ...........................Date . _. <br /> EH 7 3 2 1�S it--V. 3 SAN JOAQUi . LOCAL HEALTH DISTRICT 871 3M <br />