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. <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ... .7..r . <br /> i�' (Complete in Triplicate) <br />.......... ...... .............. <br /> Date Issued 3. <br />.................... ---._,1 This Permit Expires 1 Year From Date Issued <br /> I. 1 <br /> Application is I reby made�tSthe-Son Joaquin Local Health District for a permit to construct and install the work herein <br /> m ! <br /> described. This:�opplicotion is ade�in compliance with County Ordinance No. 544 and existing Rules and Regulations: j <br /> JOB ADDRESS/LOCATIO ............... ......CENSUS TRACT ....._.. <br /> Owners Name,.:........ .... ....... .. .. .. . .................. Phone <br /> Address .j ..............................-....... <br /> l •----....... City ---- . <br /> .._...._ ��.. .�... moo............. .. .......... .. .. ...... <br /> Contractor's Name ............64:2 -.. '..- ------------- ---• _.....License # Phone <br /> i « - <br /> Installation will serve: Residence Apartment House-E] Commercial_(]Trailer Court 0 <br /> Motel ElOther ----- <br /> Number of livi ng units:,.,.-...,.. Number of bedrooms ----__ ' <br /> 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- Clic Peat -,",-Sandy Loom- -Cla` toorn <br /> Hardpan A of�[j.� Fill Material -_.-....__.. if es: e .............--:-;-------.- <br /> �p i W <br /> (Plot plan, showing size of lot, location of system in relation t'ojwell's; buildings , etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ftip blit'sewer is available within 200 feet,} <br /> PACKAGE TREATMENT SEPTIC TAlriKs " ' Size............... 4.....-�--:- <br /> 1Liquid Depth <br /> ............. <br /> i Capacity type .......... ...... Material!-.-... ...-- -.-__ No. Compartments= *-•___..._...... . <br /> i <br /> Distance to neare'st'"�ell ............. Jo d ion ... ......... Prop line ] '.___ <br /> r-tis <br /> LEACHING LINE: ( ] No. of Lines - Le g h of eacl- ine_._._w- -.._ .. Totbl—Length ..sx..A.�. -------- <br /> D' Box Type Filter Material�______________Depth Filter Materia! ....._...___..._..........�..._....... <br /> Distance,to-'nearest:-Well .---- - ------------------__.--_--_ - Foundation . Property Line <br /> SEEPAGE PIT [F Depth .. . .. Diameter :_--._.--.--.-.- Number ........ Rock Filled Yes ❑ No ❑ <br /> A Water Table Depth _... <br /> ••-••.............Rock Size ....- <br /> Distance to rtiearesf:�Well ......... ...................._........Foundation .-._._...._ ------- Prop. line -----------........... <br /> n <br /> REPAIR/ADDITiQN(Prev. Sanitation Permit# --------- ...... Date ----------------------------------I <br /> :F <br /> Septic Tank (Specify Requirements) ..._ ....... n j� --•...... .. ............ ........ ...................... <br /> Disposal Fielci (Specify Requirements) .... __________ __.-C> __. ,e-►s!I�..-._... .: ... ` <br /> I Il D ciw existing ander qu red addition <br /> I ... ..._. ..... <br /> n reverseii�e) <br /> I hereby ertify��that I have prepared this appd Rlication and that the work will be done.in accordance with San Joaquin <br /> County Ordinanices, State Laws, and Rules anegulations of the San Joaquin-Local_Heaithtr <br /> .-District. Home owner or <br /> sed,ogents 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 fo become sAject to Workman`s Compensation laws of California." <br /> Signed -:.- -... .. ....... --- -- ----------------- - ------------------ Owner <br /> By ...- --..... ...... ------• ---------------- Title r •. .-. <br /> (ifi�oth t an.owner)� <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION A 7 <br /> CCEPTED BY _..-...--._ : ... DATE <br /> BUILDING PERMIT ISSUED .. .......... .............. ......................................-.--......- _.,..,_ .. ....... ......DATE --------------_......... <br /> ._. <br /> ADDITIONAL COMMENTS ...............`.--------- --------------------------------------------*........................ <br /> �M ....•.. :-• ----------.-.- ------c---..-.-.-...... ...... ... .................. . _... ---------.----.-.._..-----------.---------------- <br /> Final Inspection'by: ... . - . . Date ._. ./.. "..- . <br /> - SAN J QUIN LOCAL HEALTH DISTRICT <br /> c ij 13 24 n_ s a ne„ rZ7-L 7.2:3.. .. .-:► <br />