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E <br /> f FOR OFFICE USE: <br /> - PPLICATION FOR SANITATION PE �; <br /> - Perm,t No �` <br /> (Complete in Triplicate) <br /> . r <br /> Fi -- ---- <br /> This Permit Expires 1! Year From Date Issued <br /> 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 /> t described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br />�I r <br /> JOB ADDRESS/LOCATION . -- "-- "------""---- ` fiT�+�cG�1� ...... ------CENSUS TRACT -_-- --- ----------------- <br /> Owner's Name -ice-- � Phone <br /> n <br /> Address -- tN " -//P: ` - <br /> _ I - License #�.---------------------- <br /> Installation <br /> -�y - <br /> 1 � 3� <br /> �___ Cit <br /> nL <br /> Contractor's Name �r r1inG ': E� "�=C'r� -_. C� _"-c ) Phone <br /> Installation will serve: Residence r" Apartment House'❑ Commercial ❑Trailer Court i❑ <br /> Motel�❑ Other --- ---- -- ----------------- <br /> Number of living units;------- Number of bedrooms ___3- ----- Grinder ------------ Lot Size <br /> Water Supply: Public System and name ------------------------------------ ------- --- --------------------------------------------------- ---- Private <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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 /> I NEW INSTALLATION: (No septic tank or seepage pit permitted'if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size--------------------------------------------------------------------------- Liquid Depth - ------- <br /> Capacity ........... - ---- Type -------------------- Material---------""---------._ No. Compartments ---------------------- <br /> F - 6'.s Distance to nearest: Well ------------------------------------ Prop.---------------------- Pro . Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------------------- --- Total Length -Total <br /> l 'D' Box ......._.... Type Filter Material --------------------Depth Filter Material ----------------- -------------------------- <br /> Distance to nearest: Well --_____---------------- Foundation _.______._-_-.-_---.-- Property Line -------_-._______---_-- <br /> SEEPAGE PIT Depth --------------- Rock Filled Yes ❑ No iQ <br /> ` [ ] P -----�---�-- - - Diameter ----------- -- Number -�----- ---�- <br /> F' Water Table Depth ------------------------------------------------Rock <br /> Size .-- - <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------------- <br /> F, <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- ---------------Date ---------------------------------) <br /> SepticTank (Specify Requirements) --- - - ----------------------------------------------------- ------------------------------------------------------------------------------ <br /> Disposal Field (Specify Requirements) ____SGC Gf__.. a._._-f=� _ 4c1­1•_ C- ---_-_ l��— _ <br /> fif <br /> - r <br /> -------------------- <br /> i (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 licen- <br /> i 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 -- <br /> ---------- Owner <br /> p <br /> By --- ------------------------------ ------------------C 2 S,= <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> F$:' <br /> - �� <br /> APPLICATION ACCEPTED 6Y _-�- -"---"----"-------=�:��-r._:..---."_-- � " <br /> -----"---- --- -------- ------- -"---- DATE -•='--""- �---�-�--"---"�-- - - <br /> BUILDING PERMIT ISSUED - ----------------" - -- ----"--- .... . ---------------- .......-----"------ DATE ------ --- ---------------------- <br /> ADDITIONAL COMMENTS ...--..----- --- ---------- - <br /> j j <br /> ----------------- ------- ----------" - ---- - --------------- -- --------- ------"------------.............. <br /> -FinP --- y: ... "`- ' .. Date ..... 4----------- :----- . <br /> FaJ Ins ection b f''�-•� �-��� --" <br /> .-.....�---. _...-4: <br /> SAN JOAQUIN LO�C�,L HEALTH DiSTRI.:T <br />