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., <br /> # FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> :. <br /> ....... .......... . ' <br /> ....................... ........... �e 2 s <br /> Permit 'o <br /> (Complete in Triplicates` - r ----------------- <br /> .. <br /> ....................................................... . <br /> ........:............................ .................... This Permit Expires I Year From Date Issued Date Issued .7 <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 /> JOB ADDRESSAOCATION ........ I-:��._ _1�._,.... _.. � .� ..................CENSUS TRACT .....................::... <br /> Owner's Nome ., <br /> ... e <br /> Address _ :.......... ..... ...... ............................ City _...._............. -- ------ <br /> . <br /> Contractor's fVarr�e �..:.: -� CJL- G� - --- -_License # .�.��- `�.Y��Phone����.-.�— <br /> ,.- <br /> Installation will serve: Residence ( rApartment House❑ Commercial❑Trailer Court 0 ' � <br /> Motel-C] Other ............. �G <br /> ............... _ <br /> Number of living units:.......,_ Number; of bedrooms,. .� -....•Garbage Griner ._._......_ Lot Size <br /> -- '.. ............................ <br /> Water Supply: Public System and name _.....:. � { ..................................`._...._.....PrivateE <br /> f <br /> Character of soil to a depth of 3 feet: sand Silt❑ , Clay ❑ Peat C] Sandy Loam ❑ Clay Loam 0 <br /> Hard <br /> a <br /> a _p an Adobe (K .Fill MatJ❑ erial ..... If yes, type --------- .................. <br /> (Plot plan, showing sizei of lot, location of system in ,relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: I (No septic.tank or seepage pit permitted if public sewer is available within 200 feet,) f/ <br /> - i <br /> PACKAGE TREATMENT, SEPTIC TANK[ ] "Size.-.. �. gg <br /> [ l � �p= " Li Depth ....U.. <br /> Capacity ..f - ypPe --_.-.----- Material •.................. No. Compartments ......Z............ <br /> Distance to nearest: Well . ..jl�t'.C3 -- - ___.._.._Foundation ..A6............. Prop. Line .��f'.�..._...... <br /> -, ----------- <br /> t , <br /> LEACHING LINE No. of Lines Len th of each line r <br /> [ ] - g _ .�............... Total Length .... �� <br /> * } Tt <br /> i <br /> r _ - Type�Filter�Materal � Depth;Filter Material ..r/.t._l ---•----- -- -- <br /> P. <br /> Distance--to neatest: Well ........ Foundation .............. Property Line <br /> SEEPAGE PIT [ ] Depth Diameter .c --..... .,'Number ........ ...... Rock F;Iledl Yes 1 No ip <br /> F � �.Water•Table.Depth ._-__________------------------------------------Rock Size <br /> ` Distance to nearest: Well ......... __.......................:--Foundation _.:-..........-..... Prop. line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation iPermit# ............................................ Date ------------------------.._....... <br /> ) <br /> Septic Tanks(Specify Requirements) ------- ------------- ­-----•--• --------- .._..-------------- ---------- ........... <br /> Disposal Field (Specify Requirements) -----------------------------•------ --- --- ........... -----... ............. 'R_. ----- <br /> > i <br /> .............. $.. ......__-..-----...---'------.__- ........ .........:..................._...................-.------- <br /> .... ... .._._...- <br /> --.r.........:.�w.�.. _ <br /> ................. .... ............... ..................._._..-- . <br /> 4......................................... .Y_........_.............___...._..._... <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. 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 /> cis to become subject to rk n's C 3 <br /> l pensatian laws of. . <br /> Signed .......... .�. ... s...-_ .•�� --� ---- Owner <br /> --- ----- ------- <br /> i By ... .. ........ ......... ...... .:: ;.__...:.. Title ...... <br /> ......... ...... <br /> (If other than owner) a , <br /> t <br /> FOR DEPARTMENT USE ON`Y <br /> APPLICATION ACCEPTED BY . -- - - .- --- -- • ._...----- DATE --�� /.� ._- .................. <br /> BUILDING PERMIT ISSUED ...:_.. --- ----------------- ----------=---------- ...... .r_.. <br /> ..:.............:...DATE _..._:.._..._...._._._...__ ............. <br /> ADDITIONAL COMMENTS ................... <br /> ..................... <br /> -----------......---- , , <br /> -- --- --- ,/ <br /> Final Inspection by: ... ={/ _......_....--•-------•-----.__......................Date <br /> . .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _. <br /> E_ 14_ 13 24 t.-AA Q.. FAA 7172 3 K '"I <br />