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FOR OFFICE USE; <br /> r APPLICATION FOR SANITATION PERMIT <br />....._.................................��..rr.-�}.... Permit_ No. <br /> (Complete in.Trtplicate) <br />....................................................... 7C <br /> ..................................................... This Permit Expires 1 Year From Date Issued <br /> Dote Issued ...... <br /> Application <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 AQDRESS/LOCATION ...II y.�Lr ..1y:KILL. CENSUS TRACY ....... <br /> -- --------- <br /> I/Rf'��. ,else fU <br /> Owners Name ,�,....... sof? ----- <br /> ................................................ .........Phone....s�.5 <br /> Address ........../2:2... Ritl cs7c�.- li -------------- <br /> ..---•----••-• ---.... City �! _ - ................••------.._..-- <br /> Contractor's Namea�t;F..- --------• <br /> License # Q-72221....... Phone .............................. <br /> t fl ❑ 0 <br /> Installation will serve: Residence ortment House Commercial Trailer Court <br /> Motel ❑Other -----------------------------•-----------•-- <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ------------ Lot Size ................._._...._...... ............ <br /> Water Supply: Public System and name ------------------------------------..................---••------------------•--•--••----•---••••---•-.........Private ❑ t <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] -Clay ❑ - Peat C] Sandy loam C] Cloy Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ------- ------------------ <br /> i <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 /> [ ] ] Liquid Depth .......:.. � <br /> PACKAGE TREATMENT SEPTIC TANK 5ize:..................................... .. <br /> Capacity ........ Type -------------------• Material---------------------: No. Compartments ...........,..........t <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... I <br /> i <br /> LEACHING LINE [ ] No.,of Lines ------------------- Length of each line........_-------............. Total Length ......4.Q..:.......... . <br /> 'D' Box -------- ... Type Filter Material ....................Depth Filter Material ------......... <br /> Distance to nearest: Well ........................ Foundation ------------------------ Property Line ......................... <br /> SEEPAGE PIT [ ] Depth .................... Diameter ._.-_........... Number ........:_------------------ Rock Filled Yes ❑ No {] Z <br /> Water Table Depth ..........................•............:........Rock Size ------------•-----•....._ ...... <br /> Distance to nearest: Well ------------------------------------- Foundation ------_............. 'Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit..# Date <br /> SepticTank (Specify Requirements) ............................................................................................................................................ 7 <br /> Disposal Field (Specify Requirements) ---------.. ----------- .. c ..-P/7.................. .................................................•-•-•--------------- <br /> -------------------------.........•--------------------..---- ............ <br /> --------------------- -----------------. - --------------I._.........--- ......I....................... ......................................................................... <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-"J' <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the worn for which this permit is issued, 1 *hail not employ any person in such manner <br /> as to becames lett to Workn's Compensation laws of California." i <br /> Signed . .... ...- ` ��� .. Owner <br /> By ......................................................................... ............................. litle .............................................-..--.--------------------_ <br /> (If other than owner) ,•1��I <br /> FOR DEPARTMJENT USE ONLY <br /> APPLICATION ACCEPTED BY ............................. ..... ......... .. iru ......... DATE .DATE . - ---- ---- <br /> BUILDING PERMIT ISSUED ....... ...................... •• :.. _. ... ••. ...........DATE ............................:............... <br /> ADDITIONALCOMMENTS ... ....................................•....................................................................................... <br /> :. <br /> •-------------------------------------- ..... - --------- - -------...............•................ ••. ... ...... <br /> .......... <br /> FinalInspection by ....... .. .. ... . ....................................................... ...................Date _. •..�. <br /> SAN AQUIN LOCAL' HEALTH DISTRICT I <br /> F 14 13 241v Au 7/771 K (40 4 <br />