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i Wit. SUR OFFICE USE. I <br /> APPLICATION FOR SANITATION PERMIT <br /> (Compietein Triplicate) Permit Na7ri..+�d!;,� <br /> ..........................._............................. This Permit Expires 3 Year From Onto issue d 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 County Ordinance No- 5:44 and existing Rules and :Regulations. <br /> JOB ADDRESS/LOCATION <br /> .....•.CENSUS TRACT . <br /> Owner's Name ...-,....... ..f?1Yf'�L� �,� es......................................... <br /> -•--•---••••--•--- .......Phone <br /> i. Address Ssa�q cs <br /> r <br /> -��-•"-..-_...___. ----------._.._�._Sod/--..........--.................. <br /> City ............................................. <br /> Contractor's Name __- ___�./��' �o/� <br /> -----------•• ----••-_ .----..License # _I,�6."S"86 .5•.Y 3 - Yom/ <br />' Phone __-..-•••••---•........... ... <br /> Installation will serve: Residence❑Apartment House Commercial OTraller Court 0 <br /> I Motel Other .... <br /> Number of living � r <br /> units:-_..�______ Number of bedrooms _-'kGarbage Grinder Lot Size ...��-.... <br /> Water Supply: Public System and name <br /> - - ...__... ................................................Private <br /> Character of soil to a depth of 3 feet: Sand IN Silt 0 Clay ❑ Peat❑ Sandy Loom.❑ Clay Loam ❑" <br /> Hardpan ' <br /> ' P ❑ Adobe�❑ Fill Material ..............I#yes"type...,...:...•..: ......:...•. <br /> {Plot colon, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION; (No{No septic tank or seepage pit :permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ I SEPTIC TAMC <br /> FQ Siza..`�'A'.,�'� �.` ...........--- Li uid De th <br /> € <br /> Capacity Type !`�_C s�' Cv/1rt: <br /> p ty ::aid . . . Material No. Compartments .. .. <br /> " •---......_.sem <br /> Distance to nearest: Well _,___ _� :__-_Foundation �4 �O <br /> .... __„ <br /> LEACHING LINE ( J No. of Lines � . g - <br /> �len Length of each line.__.._'�E? <br /> ... Total Length in j fo <br /> 'D' Box .., ------ Type Filter Material .. a_G ...._Depth Filter Material .._.... a 1n <br /> Distance to nearest: Well _ Y .......... Foundation ,S_Prop rty Line <br /> SEEPAGE PIT ( j Depth 1------------- Diameter <br /> Number _.._"� .................... Rock Filled Yes ❑ No 0P <br /> Water'Table Depth _•--------------•---.--------------_• ---------.Rock Size .....,........................ <br /> Distance to nearest: Well ____,_'__ --------------- ..............Foundation ..........--• Prop. Line _.•--........_......... <br /> REPAIR/ADDITION{Prev. Sanitation Permit a# <br /> ..._ .....----.............................------ Date <br /> Septic Tank I5pecify Requirements) __________________ ............ <br /> ........................................ <br /> Disposal Field (Specify Requirementsl ----------- -- <br /> --- --------- <br /> ------•-•-•-•-------- <br /> --•- -- -- <br /> . --•-----------------• -••..___..-•-- ._---... <br /> (Draw existing and required addition on reverse side)-------­---------- <br /> --- <br /> I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HeaI&District. Home owner or licen- <br /> sed agents signature certifies the following: , <br /> "I certify that in the performance of the work fc r which this permit is issued, I shall not employ an <br /> as to become subject to Workman's Compensation laws of California.,, p y Y parson In such manner <br /> Signed ...... "/gN740- Seat/ <br /> `/ . ----... --•-•-• Owner <br /> BYf..__. ----- t Title ......... <br /> lIf o nerl <br /> �FOR ARTME T USiL ONLYAPPLICATION ACCEPTED B �..... �.r -- - --••-•-----------"--------- -----. DATE +r <br /> BUILDING PERMIT ISSUE "__."................... <br /> __ _ .. _ <br /> DATE "..... .......................... .....ADDITIONAL <br /> COMMENTS ---- ------------t --..___..__.---.-------,"-_-.. <br /> ---------- •------------ ----" •------ ............... <br /> ......-- ----••--. ........ -a-- ..................................•----------- ---- •----- 1-4...... .. <br /> ----------------------- <br /> --___"_"-------"---"--------•-------------„___:------•---_,.._... --------.._.--.""-,---------------- _. <br /> Final inspection by: ..---- - <br /> -- .-Date _ <br /> 1H <br /> .- --•-----•-•-------- ---"---•--.. _..-:.__....._____..__...- _40/- <br /> � • 41'i � <br /> 13 24 1-68 °' . SAN JOAQUIN LOCAL_ HEALTH k DISTRICT <br /> B/7h 3M <br />