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OR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----........- ------ <br /> . r � (Complete in Triplicate) Permit No. <br /> 4>10 <br /> ___________________________________________________ ,This Permit Expires 1 Year From Date Issued q / <br /> 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 i ompliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ._..x O ... - Cy k-cf. ..................... . . <br /> "IL __..CENSUS TRACT ....<V9_............ <br /> Owner's Name ------- @d7! �....._.. .E►_G.A!c1Ct9!._../Y. ............. -_------------Phone..................................... <br /> Address - 5 /e------- :--•---........... ----------City <br /> Contractor's Name �I�O.tt-----¢- ---- .......................License # l66 'd.._ Phone _3 <br /> Installation will-serve: <)njs fvo:Rest ence,•j7J Apartment House+❑ Commercial.C]Traller Court C1 <br /> � . Motel ❑Other----- .......................... .. <br /> Number of living units:.... Number of bedrooms ..........Garbage Grinder ...._____.._ Lot Size .3�. ................................. <br /> Water Supply: Public System and name - --• ......................._........ .....I——.... ...................... ...........................Private� <br /> Character of soil to a depth of 31feet: Sand W Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam'❑ <br /> I Hardpan❑ Adobe-❑ Fill Material ------------ If yes,type............................ <br /> (Plot plan, showing size oftlot location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No se tics tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( I SE PTIC TANK'[ ] Size________________________________________________ Liquid Depth ............................ <br /> Capacity -................Ype .................... Material............... ------ No. Compartments ----- ... <br /> Distant+ to nl=lr'Vell ....................................Foundation ...................... Prop. Line .....----------------- t <br /> LEACHING LINE [ J No. o .......... Length of each line-.-.-........................ Total Length <br /> 'D' Bo .......I.... Typef Filter Material --------------------Depth Filter Material ......___................................. <br /> Distant to nearest: Well.......................... Foundation -.._................_____ .Property Line ........................ <br /> SEEPAGE PIT [ � Depth ......_-.-_-_ -. .:diameter ________________ Number ._.__._ ............ Rock Filled Yes C] No .i❑ <br /> Water able Depth ct.....-----•••--••......•-------------•-••----.Rock Size ..............------....... •••-- <br /> Dista c to`.nearest:,Well ...._-___•_•.....................• _..Foundation --------_--------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation,Permit# .___.___.........._.--- .................... Date .........................__....... <br /> ) <br /> Septic Tank (Specify Requirenients) <br /> 1 _---------------- -- -----------------------------s-•------------•------- - --------------------------------------------•---_----- <br /> Disposal Field (Specify Requirements) ---- ......... r ..................... �- <br /> ------••---------------------•••------- ------.. ......... ------- "x% T, R_V........ <br /> ( - -------------------------------------- --- . . -•------------.--•--------•------.-------------.._..----- .......................................... <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 /> j 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 /> j "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 /> I as to become subject to Workman's Compensation laws of California." <br /> Signed .....A, .44TA9/N ----------•-------------------------•--- Owner <br /> i By ------- - ---- - ._. Jitle <br /> ner) t <br /> r R .DEPARTMENT USE ONLY <br /> + <br /> r APPLICATION ACCEPTED BY ..... .. _.. ---------•-- ----•-•--- -------------------------------•-.. DATE _. -T'•-� -.....--------•--- <br /> BUILDING PERMIT ISSUED ...................................�1 ............................._• . ............................DATE .... --.........----------............. <br /> ­ <br /> ADDITIONAL COMMENTS __I sl j�lilv ----------•-••- --- <br /> - ---•-•-----...---•---•---•.............. . - <br /> ................................................... -------•-----------------------•-......................... <br /> ----:-.-.-•------•--------------••------------------------------- -------------------------------------------- -- ................................................. ............................. <br /> 1 Final Inspection by: ._..... ..5! .e. <br /> SAN•JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M- <br />