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FOR OFFICE,+JSE: <br /> :PLICATION FOR SANITATION PER <br /> (Complete in Triplicated <br /> Permit No. --_-- - •------ <br /> - • <br /> --------------------------------- --•-------- <br /> a1 WO <br /> This Permit Expires 1 Year From Date Issued Date Issued 1.0._ .--... <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---/ I_$� -------�--------VVA A-E�----------------------------------CENSUS TRACT _-------`-------�--- <br /> Owner's Name - - -----------LSV 0-0VS-GAJ-----------------------------------------------.----------- --------Phone <br /> Address -------- �----S-------- W1_-�T--N_F_Tk------------------------- Cit -------------- <br /> � �2Contractor's Name � �- [�1� � �-----------------•-----•-- ------.License #21-39 ------ Phone - �3 - <br /> / <br /> Installation will serve: Residencepartment House-[] Commercial ❑Trailer Court '.❑ <br /> Motel ❑ Other --------------------------------------------- <br /> Number of living units-------I----- Number of bedrooms 3------Garbage Grinder _---- --... Lot Size ...... <br /> Water Supply: Public System and name -----------------------------=---------•-----------•---------------:..------•---------------------------------------Private <br /> I <br /> f Character of soil to a Oepth,of 3.feet. •_Scod;❑ _ Silt.❑. Clay -El Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------ ----- if yes, type --- <br /> (Plot <br /> _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must bep ac overs rde.) <br /> NEW INSTALLATION: (No septic tank or seepa a pit permitted if public sewer is available within 200 feet,) <br /> ' r <br /> PACKAGE TREATMENT [ SEPTIC TANK Size---- i*Q.. --.- ...-- -- Liquid Depth <br />'f Capacity ----- Type 11 F � Material__ ' 116��....- No. Compartments ---r --.:---- <br /> ---------- <br /> Distance to nearest: Well ----------50------------------Foundation ----- ---------- Prop. Line ----_.----_--_:___--__- <br /> LEACHING LINE [ ] No."of_Lines ----------------- Length of each line--___-�7 ...._. .....Total Length -----7 ...I----------- <br /> Box .--. Type Filter Material -MOCK------Depth Filter Materia! ----..-� r�----__--__--------------- <br /> Distance'to nearest: Well ------------------------ Foundation ---------------- ---. Property Line ........................ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ---..-...................--- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -_--------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------- -------- Date -----------------.----_.---------) <br /> SepticTank (Specify Requirements) ------- ----------------------------------------- ---------------------------------------------------------- :•------------- -----•--- <br /> Disposal Field {Specify- 'Requirements) ------raK------- DM------ ------ -------------- <br /> --------------------------- --------------------------------------------- <br /> ------------ --------------------- <br /> -- <br /> ------------------- •-•----- <br /> -- - ----- -------- - .------ ---- ------------------------- ------------------------------------------------------- ------------------------------- ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I hcive;prepared this application and that the workwill, be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeowner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 otkma '' Compensation laws-of California." <br /> Signed L- =----- -----'-=-=-' -- ----� --------------- ----- ---- Owner <br /> BY ...... L <br /> -------- --------- <br /> Title -- .................. ....:::-_. <br /> (,if other t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ -------------------------------- - <br /> ------------- --------------------------- DATE <br /> BUILDING PERMIT ISSUED --' -----------------------------•----- --------'-'---........--...---- ----- -DATE --.. --- ------r .4--------------- <br /> ADDITIONALCOMMENTS -- ---- ------------------------------- --•--- ----------------- --------------------- ---- ----------------- ------------------------------------- <br /> ---- ----- ------- - -- --- - ------------- ---------------------------------- ­------------------- -- ---=-- <br /> - ------- -------------- --- <br /> ------------------------------------- --- --- - - --- - ---- ----------- - ----• ----- - -- -------- - -------------------------- ------------ <br /> Final Inspec 'on by: - ------------------------ - --.-.-Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />