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FOR OFFICE 4tSEt APPLICATION FOR SANITATION PERMIT <br />................................................ .. (Complete in Triplicate) Permit No. :.`�`�� <br />..................................................... . s�-�- ��Y�� l Dab <br /> .r This Permit Expires,11 Year from Oat*Issued <br /> Application Is hereby evade to the San Joaquin Local Health District for a permit' to construct and install the work herein <br /> described. This application is jmade In compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/i.00ATi4N !.�.. .�. .�J..... , 4 i� - ...r......r..­—..CENSUS TRACT <br /> Owner's Name . . ........Phone <br /> p .T.. .�.i ...... <br /> Address .........�1.--r��r.... --�.. .......... . ..................Cit ....................... <br /> Contractor's Name .. . .. .... ........ ........ .................License # Phone 3-4C3— -. <br /> Installation will server Residence Apartment House Q Commercial{]Trailer Court Q <br /> Motel Q Other............................................ <br /> Number of living units:....1 Number of bedrooms -- --Garbagq Grinder ..--........ Lot Size .......... V <br /> Water Supply, Public System and name ...............................-- - `-�°- -------..........................................Prlvc"❑ <br /> Character of soil to a depth of 3 feet: Sand Q Slit Q Clay Q Peat❑ Sandy Loom Q day loam❑ <br /> Hardpan❑ Adobe 19 Fill Material ............If yes,type............... ............ <br /> IPlot plan, showing`size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side. <br />} <br /> NEW INSTALLATIONs (No septic tank or seepage pit parmltted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments .................... <br /> ' Distance to neareste Well. ....................................Foundation ..................... Prop. Line ..................... <br /> LEACHING LINE ] No. of Lines .......... _r........ Length of each line............................ Total Length ............................ <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ........................................... <br /> Distance to nearesh Well ........................ Foundation ........................ Property Line ........................ <br /> SEEP I g Depth . Number ........... Rock Filled Yes Q No C3 <br />�. 1111-----1111.._.... Diameter 1111.....1111._ ................. <br />` r Water Table Depth p ----•...........................11.11...........Rack Sire ................................ <br /> Distance to nearest: Well ...........................4............Foundation .................... Prop. Line ..........-........... <br /> +. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ... .......................... ate ................... .....•. <br /> ' ...--1 <br />�. Septic Tank )Specify Requirements) 1111{. �. ' . f .I 1111.. <br />� Disposol Field (Specify Requirements) ..eQ..... . . .�••• • •••- <br /> r:- <br /> 4' <br /> .... ......•..................................:.........................................r.r........_..........--r r....r... ......................r..r.........•.-1111.._............... <br /> P ... f . . _01.x..... ......... ............: .-- _. ........_....•--........._....... ..............-----........_........._.......,.,r ... <br /> 1111 .. 111.1 ... .......� 1111. .. <br /> )Drow'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 actardenu with San JW4910 <br /> County Ordinances, State Laws, and Reales and Regulations of the San Joaquin Local Health District. Horne owner or lic4w <br /> sed agents signature certifies the followings <br /> } <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 /> r a: to become su��ork n' Comer men�Hast laws of California." <br /> L Signed .. Owner ,/, <br /> sy ................ . -----...--•--..1111.. ......... title .. /l_ `.............__..........._ <br /> 1111 . . - •--- <br /> ry. <br /> llf other than owner) <br /> k" <br /> FOR DEPARTMENT USE O Y <br /> APPLICATION ACCEPTED BY ........I....................111 ._.. 1111... ............................... DATE ......:. ..:' Y.:. ...�...:. <br /> BUILDING PERMIT ISSUED ...................................I................... . __.......11..-11.......................DATE ...................................... <br /> t ADDITIONAL COMMENTS •.............••._....-•---------------............-----•.........__..._........................_................-----..........-.............................. <br /> ................ ............................... ................ <br /> I ------------------------------•--.-------.._._... _ <br /> /1 �. c ._,._ .1111.. ...... .. 1..... ...:.... <br /> ...................-_�.----•--------------...._...�� ..._.......... ... 1111. �. <br /> Final Inspection b �... 'r:, ............... <br /> ..1 _.; /.. �... /..:.................Dote . ..` ......... <br /> r EH 13 13 2h 1-60 Revt. 5i SANLJOAQUIN LOCAL HEALTH DISTRICT 8/7a 3M <br />