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rUK CiFP!CE USE: <br /> j .-.. :. z -. PPLICATION FOR SANITATION P!---- 15 <br /> k�f-/ <br /> (Complete in Triplicate) � Permit No. a; <br /> _.......... ...... ..................................... <br /> ------------ ........................ This Permit Expires I Year From Date issued 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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT!ON _10_CtC'.f.)..DW---- --------------------------------- ------------------CENSUSTRACT ......-_. ............... <br /> Owner's Name --------5./D------ 1�1-l..S.f1.S-r................................................................... ----Phone ................. .................. <br /> Address ..... .3.i............T..n'.L4s:v..d, ---- --`--F........................... city ...-S. ........................................ <br /> Contractor's <br /> Contractor's Name ---IK4-JJ--------S_AeV.'TIC....... LTA/ ...........Licens3 # 1.77.`f. 3-_ Phone -- <br /> Installation will serve: Residence [3 Apartment HouseaCommerc!al ❑Trailer Court t] <br /> Motel ❑Other .................................. <br /> Number of living units:------------ Number of bedrooms ............Garbage Grinder ... -------- Lot Size ........................................... <br /> Water Supply: Public System and name ...-............................-----------------•------------------------------.--__-•--- ...Private [� <br /> Character of soil to a depth of 3 feet: Sand j] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 0--Fill Material ............ If yes, type --------------------- <br /> (Plot pian, showing size of lot, 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 j' ] Size................................................ Liquid Depth ......................... <br /> Capacity .................... Type ----------------•--- Material-----------_--------- No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ----------------- ---- Prop. Line ..................... <br /> LEACHING LINE [ j No. of Lines ........................ Length of each line-----.---------.------------ Total Length ------------------------___ <br /> 'D' Box ...........- Type Filter Material ___________ _ _ ____Depth Filter Material .................................. <br /> Distance to nearest: Well ----------___----------- Foundation ......................__ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ---------------_-- Diameter ---------------- Number -------..........----------- Rock Filled Yes ❑ No <br /> Water Table Depth -------------- ---------------------------------Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation ..__....._..._. .... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------_........ Date .................................) \ <br /> Septic Tank (Specify Requirements) <br /> _ / _i� <br /> Disposal Field (Specify Requirements) -- -----�� � --'���Y .._.. _. /____.a� _ __.._... <br /> ... <br /> ... ....----------------------------------------------- ------------ - ......................................... ---------------_...-..-----------------------.---------------------•----- <br /> ---- ------------ ------- ------- --......................................... .........................-......1 ------. --------------------........................-......................... <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> cs to becom sublect to Workman's Compensation laws of California." <br /> Signed - c ... / --------------------------------I-------------------- Owner <br /> By - ------------------------------------------------------------------------------------------- Title _ <br /> (If other than owner] <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED aT ------------ --`----._-'. - <br /> -----------------------------------------------------.. DATE ..-/- .1..- .-.-�'�_•.--------------- <br /> . <br /> BUILDINGPERMIT ISSUED ..----------------------------------------------------------------------------------- ------------.DATE . ...... ....................... ... ------ <br /> ADDITIONALCOMMENTS ... -- --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> _. ..-- . ..................... . ........ ... ..................------------------------------------------ <br /> --- --- ------------------------- - _ <br /> rr / - - - - - <br /> Final Inspection by: .............. �_ Gr. -- <br /> ------------------------------------------........----------------------Date --` '... ..... .: ' <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. SM <br />