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FOR OFFICE L15F: <br /> APPLICATION FOR SANITATION p'gM1T G <br /> 7� <br /> Permit No. ..................... <br /> -- - (Complete in Triplicatol <br /> T <br /> � Date Issued ... ........._ <br /> This Permit Expires 1 year From Dote 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 Regulotiensr <br /> JOB ADDRESS/LOCATIIOO L -e7 - j 9 CENSUS TRACT • <br /> Owner's Name Iby✓.•Ci`svT>! a 1 'f< ' ' - - - ...phone - - -- <br /> Address ..< C°. City <br /> Contractor': Name _ ' �^ �^ t .. ......License # .F- Phone .... - <br /> Installation will serve: Residence ❑Apartment House Commercial ❑Troller Court ❑ <br /> Motel 7 Other <br /> Number of living units: . ..... Number of bedrooms ........Garbage Grinder .. .. _.... Lot Size ..... L'"�"- •••-" <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 ❑ FIII Material - If yes,type............... ............ <br /> (Plot plan, showing si.a of lot, location of system in relation to wells, buildings, etcmust be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l <br /> PACKAGE TREATMENT [ 7 SEPTIC TANK( ] Size—.....a...................W........... . . Liquid Depth ......................... <br /> � <br /> Material...................... No. Compartments <br /> Capacity .._.__. .. ...... TyP-r ... ................... <br /> Distance to nearest: Well ................ ..................Foundation .................._.. Prop. Line..................... <br /> Total Length <br /> Length of each line . ....._...... . . .... <br /> LEACHING LINE [ ] No. of Lines . ... ........... ... . g - <br /> 'D' Box ...... .... Type Filter Material ... Filter Material ..... ...................................... <br /> ............. . <br /> ................ <br /> Distance to nearest: Well .._...__ Property............. Foundation _. ..._.._.. .._. p ty Line ........ <br /> _9...... Diameter Number . _.___..__.... ...... Rock Filled Yes ❑ No <br /> SEEPAGE FIT ( I Depth ......... �����•����-���� <br /> Water Table Depth Rock Size ............. .. . ...1....... <br /> ................................... ............ <br /> Distance to nearest: Well .................................... . <br /> Foundation Prop. Line ..... ........... <br /> .0' <br /> REPAIR/ADDI?ION(Prev. Sonication Permit# .................. . <br /> ............... ....... Date ..................................] <br /> Septic Tank (Specify Requirements) -- -' <br /> Dispn_sol Field (S eGif Requirements) <br /> /�-n cf.. , rte• ' + ti 1. . ;' � _ _... ... <br /> . ... ..... .. . <br /> - IDraw existing and required addition on reverse side) <br /> the work <br /> ll <br /> e done In <br /> I hereby certify that Slt�evLaws,pand Rtules rinapplication Regulations t0 at the San Joaquin Local Health Distraccordance <br /> his t. Homo owner er liccen- <br /> County Ordinances, <br /> 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 /> /,/ ...✓ ... Owner <br /> .. .... .. <br /> Signed .t . <br /> By •lirYs'>��. <br /> ... ._. Title <br /> pf other than owner) <br /> FOR DEPA'ETMEmr USE ONLY_ •:� __,_• ,. - - ---• <br /> DATE <br /> APPLICATION ACCEPTED By !/ + -- -DATE - -- — <br /> BUiLD)NG PERMIT ISSUED - - <br /> AODIIIONAL COMMENTS <br /> _. Dote v . ... . <br /> /7 ° _._..... . . <br /> Final Inspection by. /1 e — -' ' <br /> F:M 13 :h 1-6111 !LV 51-1 SAN JOAr'Ui1J (OCAL HEALTH DISTRICT 8/7h 3M <br />