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FOR OFFICE USE: <br /> APPLICATION FOIL. SANITATION PERMIT <br />......__F:..:.....:�'......:........................... � <br /> lComplete'in Triplicate) <br /> Permit No. ..7��/.,_........... <br /> Z3 9 <br /> ,� Date Issued <br />....................................I.................... This Permit Expires i Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein l <br /> described. This application is made in compliance with County-,Ordin <br /> ance <br /> No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO 1 ...-... .._..._ ... dam............................CENSUS TRACT -......................... <br /> Owner's Name ........__--• • . <br /> .......................................... .. ...Phone ..----...--------..__.._......_..... <br /> Address .........Y .(a.4 .. <br /> -------------- -------_ City <br /> Contractor's Name .. ............ .................. ..... ... ..�?8 /.-..._-.------.--.License #/z�=1-"�� 3..... Phone 6.6_ 96o.?-.. <br /> Installation will serve: Res idence'b artment House❑ Commercial ❑Trailer Court 0 <br /> Motel [].Other ................. .............. ---------- <br /> Number of living units: /....., Number of bedrooms .......Garbage Grinder ............ Lot Size ...5 ?a ................� <br /> Water Supply: Public System and name ........................ --------...............................................-----. -----------Private <br /> r—Characterro.f_soil_to,a_depth_of3.feet:%;:�Sand'❑-- Silt❑ -4;Clay. []=-Peat❑'-==Sandy-Loomr[I�­-C-Ioy-L-ocim3 --_ � <br /> Hardpan ❑ Adobe W' •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,) LVA <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT <br /> [ � SEPTIC TANK Size...---..�.-.X::�__.�...................... Liquid Depth ..............(�. <br /> Type . ....._ Material.. ZG_ No. Compartments ...7'.... <br /> Capacity A�� <br /> Distance to Weare ,}: Well . ..... d....____.-_----.--_-Foundation la._._...... Prn Line S_..f_----_._. <br /> t i _' p' <br /> INE N of Lines - Length,ove6ch.line. . . Length ...10'?� <br /> LEACHING L� ✓ v r� � <br /> 'D' Box .._.. ,. . . Type Filter Material .. -.-Depth Filter Materiol ---,1�........i................•-• <br /> r � <br /> p� ---- <br /> Distance }nearest: Well .-. O.�f --__ Foundation .. �_0.. .... Property Line ................... <br /> SEEPAGE PIT D I t 4 ' <br /> ep h ..._..-. Diameter—�,�-....-.. Number ...-.�... ...........:.:... Rock Filled Yes J'� No <br /> . Line ... :..! .. <br /> Water—Table-Depth_---------- ---------- Rock Size J/�-..-��----- --- -• <br /> 1 ► --/-------------•-------Foundation Prop <br /> c <br /> Distance to nearest: Well .._._./ <br /> 1 1 � -'j-� <br /> Sanitation Permit# ... Date ---------- <br /> Septic <br /> ------y j i <br /> Se tic Tank (Specify Re u <br /> REPAIR/ADDITION(Pryv. irements) ... ...._..1._____................. <br /> - ---------------------- - - ---- -------.-.-----. .......--- <br /> Disposal Field (Specify Requreme Requirements) .------. <br /> } V, t i....._...- <br /> ..............---.--------------- -- _ - ---------- _ -- ------- -- - ... _ _ _ -- <br /> ....------. . . .. . <br /> ...... . . ... ........... ....... — T <br /> (Draw existing and required addition on reverse side) <br /> I 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. Horne 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 .issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .:............................. ----------- ----------- Owner <br /> y i�a.t F <br /> y ._.....- --- - -------------•-----._ ._ : Title ...- .. ...r........_. .... -1...�E`� +_<:�._*..._-..-... ,` <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY k <br /> APPLICATION ACCEPTED BY ... r:.... -------•.. ................. .- ......... DATE .................... <br /> BUILDINGPERMIT ISSUED .............................. ........................................._......... ...........DATE ........____............. <br /> ADDITIONAL COMMENTS ------------------------------------ --------- <br /> ................................. .....-• . .. ........ <br /> ---...-•-•..............................._...r_ ._....--------- <br /> �- T. :. �._� Q ";------------- <br /> Final Inspection by: ............•--- .. ................ w s_ :..-.�"` ate :/:`a3 ..T ..._......_.._.._... <br /> ..........- -------- - ------ - ... ----- <br /> SAN JOAO�iN-kOCAit HEALTH 'DISTRICT <br /> a <br /> .,E.-He_13,�,24 I.'6A Phl-i-SAA 7/79 3 M_.. - i <br />