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rVK Lprrnx MCIAPPLICATION FOR SANITATION PI FAIT <br /> ::.......... ._.. ._.............. Permit No. ZS..-AS... <br /> ICompleto In Triplicate) <br /> Date Issued �.-.. -.�.� <br /> This Permit Expires 1 Year Ihrerrh Date Isswd 1 <br /> Application.is hereby made to the San Joaquin Local Health District for a permit to constnict and install .the work herein <br /> described. This application Is made 10 mplionce wi County Ordinance No. S49 and existing Rules and Regulations: ;II <br /> i <br /> . . .... <br /> _..............................eCENSUS TRACT ............. . ......... <br /> Owner's Name ....: - ...... ............... `' ...... .... .Phone ..............-..................... <br /> Address ..... r' ........... ........ .. . ............City ........... ... ... .. . ........................................ <br /> .... <br /> Contractor's Nam® .... ......__...� ...................................................:..License# .--•..... .............. Phone ..:............-•---.......... <br /> Installation will serve: Residence Wportment House Commercial❑Trailer Court ❑ <br /> Motel ❑Other.... . ........ ................. ... <br /> Number of living units:,.._..J.-Number-of bedroom'.. Garbge Grinder"g € ----- ............ Lai Size ...:�_ .- - ----•- <br /> Water Supply: Public System and name ................................».._---..._.-•---------._...........-..........................._........._.Prhrats <br /> Character of soft to a depth of 3 feet: Sand❑ Silt❑ . Clay ❑ Peat❑ Sandy Loam❑ day Loam <br /> s Hardpan Adobe❑ Fill Materlal ............If yes,type............... ............ <br /> !Plot plan, showing site of lot, location of system M relation to wells, buildings,' etc. must be placed on revw" side.) <br /> NEW INSTALLATION:- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 4 <br /> PACKAGE TREATMENT" <br /> [ ] SEPTIC TANK Size................................................ Liquid Depth ......................... <br /> Capacity .................... Type ............ _..._.. Material...................... No. Compartments ................. �. <br /> P - <br /> Distance 'to nearest: Well ...Foundation...................... Prop. Lina - - ` <br /> .I:ACHING LINE ,� � •-•------•---------... <br /> [ } No. of Lines ....................:... Length of..,each,line ................... <br /> Tota! Length ............................ tt��1I <br /> 'D` Box ............ Type filter Material ....................Depth Filler Material ............................................ s�� <br /> 10 Distance to nearest: Well • Foundation Property-..Line <br /> ....... ; <br /> SEI:PAGE PIT "�:�. ............. . .... �- <br /> SE ,.�_ [ ) �Dapth l Diameter .......-•---.... Number ........................... Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ..................... .......'.........-----Rock Size ................................ <br /> Distance to nearest: Well ........... ..................foundation . ......... .... Prop. Line ..................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# .Ufa':Z ................. Date .............................. <br /> Septic Tank )Specify Requirements) .............. .....•:....:.. _.. �. <br /> ©�sno l fi d [Sped Ra uirements), ...... ... _ ._ -. ... .p �� :: :° ..�.... <br /> - .�. -. `.... ... .... .. .. s .... .............................. <br /> ...............................(Draw existing and required addition on reverse side) ---..•... .... . . ... . . F <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owin+ar or lice"- <br /> sed agents 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 becom subject to Workman's Cornpens ion`laws of Cali(ornia." . <br /> Signed S:gn y... .... . .. .... Lc� <br /> �1 _ .. .4. --..... Owner <br /> (If o#her than owner) - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. �.... r`�:......................::..:.................................. ..�. DATE . <br /> BUILDING PERMIT ISSUED ._ - <br /> y. <br /> tE fi <br /> ADpITIONAI COMMENT5 .-.-.J? ,P7"! '' E�e <br /> _ f ... E <br /> .......................................--------.........._. -.. ...................................... ..................--........ .......--------------- <br /> 4 <br /> tFinal Inspection by: ................. . .a..........-----•--.....------------••••••--...............-. ..................Date ... . . <br /> �� 2L 1-6A Qom. SAN JOAQUIN LOCAL HEALTH DISTRICT �7b 3H <br />