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FOR OFFICE USE! APPLICATION FOR SANITATION PERMIT <br /> Permit No._ :. �.. <br /> i -•----•----•........................................ <br /> � �' ... tCaenplete In Triplicated ___....._ <br /> This Permit Expires I 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 Regulptionsc <br /> JOB ADDRESS/LOCATION 7_30 _......._.' _._.._. 4,1-5qe��...'e �,....................CENSUS TRACT .........__............. <br /> j Owner's Name s�.i9` . _%......�:.._.....i 94 '. '/f.........-•----... ..................................Phone ........__............:.......... <br /> -� <br /> Address ----------------------5..�'''?:� - ..... City ............:...._._...............................� ..................... <br /> Contractor's Name --------- I-------------------------------------------- -_------------ _-------------.License # ....................... Phone .._--_-_----................ <br /> iInstoliation will serve: Residence ElApartment House( Commercial❑Trailer Court <br /> I Motel (]Other-------------------- _....•----•---------- � o _ <br /> Number of living units:--,!-_-/_._ Number of bedrooms ----A--.2,. Garbage Grinder ---N ___ Lot Size ............................................ <br /> Water Supply: Public System and name .................... ..................... ...........___......................................-.:_-......Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt(3 Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam ❑ <br /> �I Hardpan[j Adobe Fill Material ...._....... If yes,type ............... ....... <br /> II ..... Q <br /> (Plot plan, showing size'lof 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) }Q <br /> PACKAGE TREATMENT (:] SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth .................... �+ <br /> Capacity ----------------- Type -------------------- Material-------_----------.- No. Compartments ...................... <br /> ' Distance to nearest: Well --------------------------------_.foundation ----_---_--_---.----- Prop. Line ...................... <br /> . <br /> LEACHING LINE ( ] No. of lines ------------------------ Length of each line--------------- ...__-___... Total Length ............................ <br /> Ii <br /> 'D' Box ............ Type Filter Material ....................Depth filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation -_-.----_---.-_-_ Property Line ........................ <br /> SEEPAGE PIT ( l Depth Diameter ................ Number ............................ Rock Filled Yes ❑ 4No.0 <br /> Water Table Depth ................................................Rock Size ----_--- __...........------ <br /> i <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------_--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --•-------------------------------•---•----- Date ----------------------------------1 <br /> 11 E�rfl/.E' 't, 5 f STS a.� 7 s�9P�ii/ <br /> Septic Tank (Specify Requirements) --------------e '_......._.......,. ?x�' ....................... --....:-�--•---F-----............... ...... <br /> Disposal Field (Specify Requirements) ----- ------ - ----•------------ <br /> ,; <br /> I� <br /> ---------------------------- ---------------------------------------------- ......................------------.-----------------------------------------------I............. <br /> 11 (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be clone 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 aoents 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 /> r <br /> Signed <br /> i (If - <br /> -----------------------------•-------- Owner an owner] <br /> By ----;------------------ - •-----------•------------- Title -_. <br /> _..----.-..-.-.._- .._-. --- ---------------- .-----...---------- <br /> ` II FOIE EPAR ENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- --------- ---------- DATE .-.�...=�� ---------------- <br /> BUILDING PERMIT ISSUED ........... . __. ...._....__...__-- DATE -•- - <br /> ---- - - -- - - <br /> ADplTlQNAL COMMENT <br /> ----------f`� ..ZP_.-_ y !!�? 1.�. _ .._GS_ _ Q _. f -Cr_ �......._.., <br /> ---------•- ----------------------------''-----------------------------------------%­t---------- -----------------------------............_....----.............. .................................. <br /> ------------- --- -- ----------------- --------------- ......--------•------- ---...-.._.--.. : <br /> Final Inspection -- ---•- . . -----•••-•-•-•--•..................................Date ._. ._. .. . .. <br /> EI 13 2!i 1--68herr. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> I <br />