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t <br /> • v � I <br /> FOIL OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -- - --------- --="----- - -------------- ------- - Permit No: �-- ----------•----- <br /> (Complete in Triplicate) <br /> -- -------------------•--------- - Z `1� 7?� <br /> __ I <br /> -------_-------- --------------------------------_--___ This Permit Expires 1 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 /> `� �-�•� � 1 �-�/ T ����j f�-`�- <br /> 12-o- O k <br /> JOB ADDRESS/LOCATION. ` - C YI C-------- CENSUS TRACT . <br /> f -- <br /> 11 - - `z`-`!l,/ 7 _. Phone <br /> Owner's Ne .. !_. � = _ ----------------------- <br /> G <br /> J <br /> ,1 ' - � -----•- City ----- --- -_a�__'G--- <br /> Address _�7 �------- -` `- ,---- r---'----�--------- --------------- - - ------------------ <br /> ---------- <br /> Contractor's Name -------------L = -------- ---.License # 7--.V-1_,72) Phone ! f-'- lf� <br /> Installation will serve: Rdsidence ❑ Apartme t ouse,❑ Com,p <br /> >ercial 'E]Trailer Court l❑ <br /> / �' � <br /> Mote! ❑Other -- - -��__--E°_--- -- = �--c - )e5, <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[-1Clay ElPeat Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- .6 <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted//if public sewer is available within 200 feet,) lip, <br /> PACKAGE TREATMENT { ] SEPTIC TANK' GSize;T-- - -Xulv,6 <br /> --_. Liquid Depth ____�.--------- -,- <br /> -------------- <br /> Capacity O <br /> -yC__ ,___,TypeZt <br /> d Material No. Compartments ______ ___ <br /> Distance to nearestAWell ____ Z% r t_________________ <br /> Foundation _1_�'--r_________ Prop. Line ---------A4- <br /> L ACHING LINE No. ,.of Lines _________________�_ Length of each line-/-/ - �e'------- Total Lengthy <br /> 1 <br /> .�'D' Box _____ __---- Type Filter Material Depth Filter Material � �--------------------=•----_-__.--__ ' <br /> Distance to nearest: Well — ------------- Foundation - %_____________ Property Line t ---_____--'..... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter -----------_---- Number ---------------------------- Rock Filled Yes No 0 <br /> Water Table Depth ----` ---------------------------------------Rock Size -------------------•----- ----- <br /> Distance to nearest: Well ----- _________________________________Foundation -------------------- Prop. Line __..______-_-_______-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --"----- <br /> ------------------------------------- Date ____-________---------------------} <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------- ------ } <br /> DisposalField (Specify Requirements) --------- - ----------------------------------------------------------------------------------------------------------------------- <br /> -------------------- - (Draw exisfiing and required ad' ---------------- ------------------- ------------------- ----------------- <br /> ----------------- ------------------- -- --- <br /> addition on reverse side) <br /> 1 hereby certify that I have prepared this 'application and that the work will be done in 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: , I <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 be c :es lect to ork an's Compe ation laws of California." <br /> Signed -- --- ; LCL ------------------------------- <br /> Owner <br /> BY --------------- - �; y �y'� Title <br /> (If ofiher tha6 owner] <br /> F PA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ------------------------------------ DATE - =f ----------•---- <br /> BUILDING PERMIT ISSUED -------- - - ----------------------------------- <br /> ---DATE <br /> ADDITIONALCOMMENTS - - - ------- ------------------------- ---------------------------------------------------------------------------------------- <br /> ----------- _ <br /> ---- <br /> -------------------------------------------------------- -- - - -- -------------------------------------------------------------------------- 1-1-­­ <br /> FinalInspection b --------------------------- C_- v ---------------------------------------------------------------Date _ "-r?�_7� ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> e U n t 1A.0 Ds.. 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