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FFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 0 %s- � <br /> 10- ...... . ..*. .. ............. (Complete in Triplicate) Permit No. .:..........I.�::.. <br /> �. ..... <br /> . --.� ...................................... This Permit Expires 1 Year From Data Issued Date Issued ..1r--V7S- <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. x549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ION .....1.` .. ....... ..... --.....LO.. -U..!........-..._.....CENSUS TRACT c� <br /> r <br /> Owner's Nome ... x.tW <br /> 145......... ........... ........Phone . '� ./..�5.... <br /> .. .. ....... . ... <br /> Address ..L. .g .....,. !.. . ....... CitSC ©/l) <br /> /� ��tY ............ ... � (1...... .......----.... <br /> Contractor's Name .��K!. Lam1C. �... ..........License 4".6.Ci.6i. Phone V?-Y7f71A6G <br /> Installation will serve: Residence ['Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other _....^......... __..... <br /> Number of living units: ... Number of bedrooms ..s--,. -Garbage Grinder � Lot Size .. .. <br /> Water Supply: Public System and name ......:........................... ............................... ... _. Private [ <br /> Character of sailto a depth of 3feet , Sated ❑ . Silt❑�C �❑ ,Peat❑Sandy Loam❑.. Clay,Lao, <br /> Hardpan Adobe ❑ Fill Material ...._. ..... If yes, type ............................ <br /> (Plot plan, 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{ ] Size...... ................. ...................... Liquid Depth ........................ <br /> Capacity . _. . .._. Type -------------- Material...... ... . ...... No. Compartments ....................-.0 <br /> Distance toy nearest: Well ._..... ........................Foundation ............:......... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ... _. .... _. Length of each line .. ..... .... ...._ .... Total Length ........ .................. <br /> 'D' Box .....ikk.-.., Type Filter Material ....................Depth Filter Material ------....................................­ <br /> Distance to nearest: Well ........................ Foundation Property Line ........................ <br /> SEEPAGE PIT [ ) Depth _� ......... Diameter ................ Number . ...... ................... Rock Filled Yes ❑ No Q <br /> Water Table. Depth ...__............................. . ..----Rock Size ------ <br /> P. <br /> Distance to nearest: Well ..................._ _ <br /> ...--..............Foundation - ......... ....... Pro Line ..........-........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........ ............................... ... Date ----------------------------------I J <br /> t /1 <br /> SepticTank (Specify Requirements) ................................................... .... .. .................. ..........................................................— <br /> Dispasol Field (Specify Requirements) .. ,. ._ ......... . . _ .. <br /> .... . .. _.:... . P <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 San Jooquin <br /> County Ordinances, State laws, and'Ruies and Regulations of the Son Joaquin local Health District. Home owner 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, 1 stroll not employ any person in such manner <br /> as to beco su Oct' o, �Wiirkma ompensation s.of California." <br /> Signed .. : 's�s-r. ... �............ ... Owner <br /> By ...: �Q�. C4 Q ....................:.......... Title . .... _ _..._................. . ._ ..................._... ... <br /> If of er than owner) <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ._ .. . ............... .................. DATE'....hac"1..-...75............ <br /> BUILDING PERMIT ISSUED .. _... ._......._.. �..__.. ....... ............... . <br /> _.._.................._...- -..._............... ... ......_.-....DATE . . .................................... <br /> ADDITIONALCOMMENTS . ................. ... _.......... ._................ .._............... ..................................._............... <br /> ................................. <br /> ...... .................. .......... <br /> ..__........ . .......... <br /> ...------ <br /> .......... <br /> .... <br /> ._..----- <br /> ---- <br /> --- <br /> . ............ <br /> .---- <br /> --................... <br /> ........................... ............... ------- .............._........ .. ...._.-_................................__........................................-................ <br /> .. <br /> .................. <br /> _....................... .. ....._....... . .......__............ ... .... ........... <br /> Final Inspection by: .... .... . . --- ----. . ................................._................_.............-Date ...b._- 1.`ZS.............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT [ <br />