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FOR OFFICE USE: APPLICATION 'PC+R SANITATION PERMIT , S_ <br /> .......................:....... ..... .....-.. Permit Na. . ... '... .... <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ..... .�r.:�.._.:�.. <br /> .............__1 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION .........21:1.40-..F,;,...Har_d .-n9..1I9,Y•................. ............. ._......... <br /> I1 erLte5 Rest Home ..Phone ._....6:......_.275 <br /> ....Owners Name �:�.�_._.....---• ......................................................,.---M�...----•---------• .............. <br /> City Stkn,L......-..............:....... ........................ <br /> Address --------------------------------------------------------------- ..................... ........... <br /> Blackard' S Septic Tank " ...-�--License # .-26.8. 51:._•._. Phone--....46. --7.0� ..... <br /> Contractor's Name .. ........... ---• .............................• �... <br /> Installation will serve: Residence ❑Apartment [Iouse'Q Commercial E]Trailer Court ❑ <br /> t <br /> Motel ❑Other_......::.I................................... <br /> Number_of,.Iiving-u.nits:-._3........ Number of bedrooms ......3....Garbage Grinder ............ Lot Size ,..-..2.QQ.'. C .O Q.#.......-•----•• <br /> Water Supply: Public System and name .......................................................................c1t ...._...._.Private <br /> ................ El <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ ' Peat'[] Sandy loam [3 Clay Loam ❑ <br /> Hardpan ❑ Adobe:E] 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 .......................... 0 <br /> Capacity Material.............. .. No. Compartments .... ........I........ <br /> Distance to nearest: Well ....................................Foundation .................----- Prop. Line ................___--: r <br /> .LEACHING LINES No. of Lines .......1.............. Length of each line----------4-o l....._..... Total Length ............................ <br /> =. . f t�— - <br /> 'D' Bax ..1....... Type Filter Material ----------2•..:==-:Depth'Fiiti;r Materiat'_..:':- "19'.'.." :............ <br /> r -x � � 10 ' <br /> Distance to nearest: Well .- ...... Foundation .............. },Property Lie --------•-•-- ......._. <br /> SEEPAGE PIT M Depth -....2-. f Diameter --_.33_'.......-NumberRock Filled Yes .No ❑ <br /> Water Table Depth --------- ---------------Rock Size ..2n�...--...... <br /> ` <br /> Distance to nearest:-Well _...s..e..".--------.-•-••�---Foundation .........30.. Prop. Line _....__.1.D.'.--.... f <br /> f <br /> REPAIR/A�6'DliTf N115rev. Sanitation Permit# I <br /> •........................................... Date --•-----....----- ) <br /> SepticTank (Specify Requirements) ..........................•-----------....................................................................................................... .. <br /> Leach Line & Pit...33"X25_r............................ .... .. <br /> h Disposal Field (Specify Requirements) ........................... <br /> . ••------ ----•--------- -----------...............------------ ...... <br /> - <br /> ..........................•--•---•---- <br /> (Draw existing and required addition on reverse side) ... <br /> I hereby certify that I haviJirepared 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 Jo-aquin-`Locai�Heaith-District. Home owner or licen- <br /> .sed agents signature certifies the following- <br /> '"I .certify that in the performance of the work for.,which this permit is:i'ssued, I shall-not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California."`��' T <br /> Signed ...... ......... ..................... ... .. ....................................... Owner <br /> By ............. • � . ...... ............ <br /> Title ....-cQX1 7r G.�Qx <br /> (If other than owner) <br /> FO ARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ---- .z --••• ---• • -- ......-.................................................. , DATE ...........--- <br /> BUILDINGPERMIT ISSUED .......... •-•............................I..----..... . ---:....DATE ............................................ <br /> ADDITIONALCOMMENTS ... ...... . - ...................................................................I—..................... ......---------... <br /> ....._r^-• .............................................. :.............. - . ......--- .-.............._ ..... . <br /> ------------------ .-. <br /> ...... .-----------..-_.-------------I—....---- .•--- .................... _ � <br /> D t <br /> Final Inspecti bY' . ... . a e ..... ..... .. ....: . . <br /> N AQUIN LOCAL HEALTH DISTRICT <br /> , n ni. - — 71723 K <br />