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FOR OFFICE USE. <br /> APPLICATION ICOR SANITATION PERMIT <br /> (Complete In Triplicate) <br /> Permit No. 7 .... <br /> This Permit Expires I Year From pate 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-Coun"rdInanj2p No. 549 and existing Rules and Regulations: <br /> a �} <br /> JOB ADDRESS/LOCATION ../ ---:._ S?^i E S i.ENSUS TRACT <br /> F ..... <br /> Owner's Name .......:......Y�v . .............�.:� . ......... .......... <br /> _Phone .............. <br /> .... <br /> ............... <br /> Address `...� <br /> Contractor's Name ... --- --- License # ... Phone .. ... <br /> .. . <br /> Installation will serve: Residence Qd Apartment House Commercial ❑Trailer Court 0 <br /> f Motel ❑Other............................................. <br /> Number of living units:--•-__....._ Number of bedrooms -------------Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name .................................................................�.... <br /> .......... <br /> ...... ........::...Private ❑ <br /> Character of soil to a depth of 3 feet: Sand b Silt❑ Clay ❑ Feat❑ Sandy Loam ❑ Clay L`aam Q <br /> Hardpan❑ Adobe'Q Fill Material ...... if yes,type ............... ............ V . <br /> (Piot 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{: Liquid. ... Liquid Depth <br /> Type+ <br /> Capacity /. -D��--- !tic---••©-- Material ...................` No. Compartments .. _ .... <br /> Distance to nearest: Well -•-1-{`-----•..............:.Foundation ._._ • ......1 Prop. line ........ <br /> LEACHING LINE No. of Lines ---._v_._............... length of $adiine__11.0.-O...:.:......:.Total length _...._ . . <br /> 'D' Box .....�.._.. Type fitter Mater�_-A.,Depth' <br /> ,Depth Filter-Material -Z! . <br /> . •.,.......................... . <br /> e. �^ r <br /> Distance to nearest: Well Foundation �.�;�"%�.... Property Line ......Z_____.....__. ' <br /> SEEPAGE PIT { ) Depth ----------- ----- Diameter --- ............ Number .. ...::....^`...._....... Rock filled Yes ❑ No 0 <br /> Water Table Depth -•----------------- ............. •------_-:._Rock Size --•......------........_.....--- <br /> Distance to nearest: Wel! ...' .- ":_:._Foundation ' Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------•-..-_-_-----_----- Date ....--..•_.................... <br /> Septic Tank (Specify Requirements) ..:.............. �. <br /> � ........... ..... .... .. ........ .--•--....... ----- ---- <br /> 1 <br /> Disposal Field (Specify Requirements) ------- <br /> ------------------­---------- <br /> ----- = - <br /> f •- l <br /> •-------------------------------------------------............................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San 1 Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.Distdcf. 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 issued, I shall not employ any person In such manner <br /> as to become subject to rkman's Com en tion I ws o California." <br /> I � Comp <br /> en <br /> ----- � Q + QJ112,[ ---. <br /> XJL;• - 8vvrre� <br /> BY ---- <br /> (If other !_... Title -- �'` ................ <br /> than owner) <br /> FOR DEPARTffiEN_T WE OIYLY <br /> APPLICATION ACCEPTED BY_----------------------------- <br /> Y-----------------•------•------ ... -------- DATE _.5: -Z`...---- ---------------- <br /> BUILDING <br /> PERMIT ISSUED ---------- . �PO4��l-----•- --• ------ . ..•---•. ...... DATE ................................ I <br /> ADDITIONAL COMMENTS ------------ ........................... ---•---------• - <br /> ........... •---------------------------- - •----- -------- ------------•---•------------•---•---•--•------- <br /> Final Inspection by: .......................................... <br /> .......................................... <br /> ---- -•----..............--•--...--••----....4TRICT... <br /> .. -•--Dat" -- e ----5'" a` <br /> _ _.. .- ............................................ <br /> EH 13 2h 1--68 i�ev. 5m SAN JOAQUIN LOCAL HEALTH 674 3M <br />