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• FOR OFFICE USE: <br /> APPLICATION,.FOR.,SANITATION PERMIT / S <br /> Permit No- ------------ --- <br /> ---------=--------- - <br /> -3a (Complete in Triplicate) <br /> Date Issued <br /> ' - -------- <br /> This Permit Expires 1 Year From 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 /> r r <br /> )013 ADDRESS/LOCATION �T __-,-_ <br /> �6Z ��._ CENSUS TRACT <br /> Owner's Name ------------------------ ------------------- ------ Phone .----------------------------------- <br /> Address .......?6�---- so..... _PClvr---------------------------------- City ���Gl�'l�1rf-----------------------------------••-•---•-- <br /> Contractor's Name /���~ -------SLJI-P CZ _License #/2�. 03--- Phone <br /> Installation will serve: Residence N.Apartment House❑ Commercial :❑Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <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'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ,[:] Clay Loam <br /> Hardpan ❑ Adobe_R Fill Material ------------ If yes,type ---------------------------- <br /> f` <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,) �J <br /> PACKAGE TREATMENT I ] SEPTIC TANK'[ ] Size------------------------------- ------ Liquid Depth --------------------------6I <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ -1" <br /> Distance to nearest: Well ------------------------------------Foundation --------------------.- Prop. Line -----------------.----� <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-------------------.-------- Total Length ------------------ ---------- <br /> 'D' <br /> ----------------•---------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------------.--- n <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -----._.__________--.--- `( <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑*— No 0 1% <br /> Water Table Depth ---------------------------------------=------- Rock Size -------------------------------- <br /> 7to <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- 1; <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------._-.-----------------) <br /> e <br /> Septic Tank (Specify Requirements) -------------- -------------- ---- ------------------------------------ --------------------------__---------- ---------------- <br /> Disposal Field (Specify Requirements) ___.P�©__r___ __- J/VLr--�1-2--__/ LT_______________ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------- <br /> -------------------------------------------------- -- ----------------------- ---------------------------------- --------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I I hereby certify that I have prepared this application and that the work will be donein 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 /> 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 sub'ect to Workman's Compensation laws of California." <br /> Signed ----------- ----------- --------- ------------------------------------------------------- Owner <br /> BY Title <br /> (if of a than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY --- --e ------- 4 1��j .e�.Ye�--- --------------------- ------------------------. DATE ------- '. <br /> BUILDING PERMIT ISSUED -----------------------------------f----------------------------- ----------------------=------------ DATE -------------------------- ---------------- <br /> --- ----------- - ----- --- -� - ---- --------------------------------------- ---------------------- ------ <br /> ADDITIONAL COMMENTS ------------------ ------------------- --- --- - - ------------------------------------ <br /> --------------- <br /> ---------- <br /> -------------------------------------------------- <br /> -------------------------------------------------- ?�-- ` ---- ------ <br /> ---------------------------- -------------------- <br /> -- ------------------------------- <br /> Final Inspection bY- ------------- - - --- -- - --------------------------.Date- --------- <br /> SAN JOAQUIN L HEALTH DISTRICT <br /> I E. H. 9 1-'b8 Rev. 5M <br />