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. FOR OFFICE USE: y <br /> APPLICATION-FOR SANITATION PERMIT <br /> -------------- Permit No: 197 <br /> (Complete in Triplicate) € <br /> ----=--------- --------------------------- <br /> - Date Issued//_-/5-4_ <br /> This Permit Expires 1 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. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ©.I-OO H "'7`------R_D__ --••-------- ---- -CENSUS TRACT - ------ <br /> _0��c `--- _R- - Phone <br /> Flly------//76—/---- <br /> Owner's Nameg r <br /> --�- -y <br /> -- - <br /> Address � �� ��`R-- --- .------------------------------------� � � -�='= City !1'!r�A----- --------------------------- •----------•------ <br /> -s Name WED----- ----, - .License #/-�_�3�6------- Phone <br /> Contractor ' ;----7.License <br /> Installation will serve: v_ : .Residence _.Apartment.-House`f❑ Commercial:❑Trailer Court ',❑ <br /> Motel ❑Other ------------------------ -----=----------- <br /> Number' of� living units:--- ----- Number of bedrooms ___�___._Garbag""e Grinder��r-�- Lot Size --------- <br /> Water <br /> --- -•-Water Supply: Public System and name ---------------------- --- - ---------------------=-----------------------------------------------------------Priyate <br /> Character of soil to ,";depth of 3 feet: Sand ❑ Sift❑ Gay E] 1,Peat E] Sandy Loam Clay Loam;❑ <br /> Hardpan ❑ - Adobe-E] Fill Material y _ If yes,type <br /> '(P'l'ot plan, khowingl�ize of lot, location of system in relation to wells,_.buildings,_etc,_m.u.st„-he-placed on reverse side.) <br /> NEW INSTALLATION' (No septic tank or seepa pit permitted if public sewer is available within 200 feet,) f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size-__`u__ __l.r�__x__5 .. —_. Liquid Depth'----,5------------- <br /> P <br /> MteriaE _ CompartmCapacity Type ents <br /> ,"stance "_--Foundation I ._ __+___-- Prop. Line <br /> __ --_-------- <br /> _ __V <br /> _r.."!_____ty - <br /> / l ��O - <br /> [N of Lines __._ _"1____ Length of each line___._ D_ ___.-- -__ Total Length <br /> LEACHING LINE � ' <br /> � 'D' Boxy - Type Filter Material Depth Filter Material ------ <br /> •-------------- ---- <br /> Di stance-to-nea restr <br /> ---Distance-to-nearest: a <br /> -Wel i _r- ___ ____Foundation- _ ._ Proper) Line ___5-_________________ <br /> SEEPAGE PIT [o I Depth _ -`_ ------ Diameter /i"__X_____--_ Number --------- `---- Rock Filled Yes 2'o i❑ <br /> Water Table Depth ----�_; --------------------------- -------Rock Size f s <br /> I Distance to nearest: Wel! ---7�____________________________Foundation _._f9____'4-- Prop. Line __ ____"--`__.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-------.---------------------- ------------ Date -------------•--------------------) <br /> SepticTank(Spedfy_Requirements) ---------------------------------------------------------------------------------------------.---------------------------------------------- <br /> r"`s '__1 <br /> Di posalL Field (Specify Requirements) <br /> •` ) � <br /> r ----------- ---------------------------- <br /> ..,___--�------- <br /> . <br /> �. Draw existing and-required addition..ontreverse'side}. -_ w. <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. Nome owner or - <br /> licen-sed agents signature;certifies the following: i• <br /> ",l Certify that:in�the peyrformance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be bje to, o kman's Compensation laws of California." + <br /> Signe��/�/y/-/�-J1��� --� - --=----'•--- ------- - - ---- ------------------------------ <br /> ___ Owner <br /> � fh 1 <br /> i Title <br /> ------------------------ <br /> 1% <br /> .�(Ef o` er tl`ian owner) <br /> FOR DEPARTMENT USE ONLY <br /> f� DATE ...... <br /> APPLICATION ACCEPTED .BY � R----•-------------------------------------- ----------- -- -- <br /> BUILDIIIG PERMIT. ISSUED -- ---------------------------DATE _--- - ---- ---- ------ <br /> ----------------- <br /> _ _ _..__ . <br /> ADDITIONAL COMMENTS` ------------ <br /> ---. - �_.. - -__ - -------- <br /> -- ---- --- ------------------------------------------- <br /> -- <br /> .----------------- - --- -- - ------------ - ----- --'---- - <br /> ------- --------------- ------- - -------------------- - -- - -- <br />'* Final 1nsPe..t <br /> ------------------------------------------Dae <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 .1-'6B Rev. 5M <br />