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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> v �- <br /> ------------- --- ------------- l°. 3 Permit No. s . <br /> 1Complete in Triplicate) <br /> ----------- ............................................. This Permit Expires t Year From 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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATi N ..---- .. �3 ., c.11�7 s�.�O�o...� CENSUS TRACT ..................•. <br /> ,........................... ..... <br /> Owner's Name :. lz �'-���'S...................................... Phone :,............:.......t.�.... <br /> ` • <br /> Address ........ .....................•...---....- <br /> .................f �_aCity ....J.a.f_�7-,a .ty. ►.. <br /> c _:; SIC'.....:..........license # 17—.? Phone <br /> Contractor's Name _-_ __ -d�3_ _ ' _________�'c <br /> Installation will serve: Residence[ Apartment House Commercial OTroller Court 0 <br /> ' Motel ❑Other_.41 ik&4P--... <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ...... ..................................... <br /> t <br /> Water Supply: Public System and name � ❑ <br /> Private <br /> Character,of soil to a depth of 3 feetScind ❑ Silt❑ Clay {] Peat❑ Sandy Loam 0Clay Loom =] <br /> Hardpan Q AdobeFill Material ............ If yes,type............... ............ O <br /> (Plot plan, showing size'Of lot,.Iocafion 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 TANKI-I Size e•. q p <br /> ...�... ..,.....-.::.:. ...... Liquid Depth . <br /> Capacity j. ._.__.._ Type`..X2 9.S�Material_.L��l.s........ No.. Campar#ments ..:_. .........i , <br /> Distance. to nearest: Well -___.�f._ ...........4'. ....1.71..... prop. Line ..-' ........... <br /> cr <br /> LEACHING LINE [ j No. of Lines ________________ Length of Each ling.. .�_7 Total Length �r ...... ........ <br /> 'D'+Box Lc . .. Type Filter Material Filter Material 14e.-- <br /> .............. <br /> Distance to nearest: Well ... �r4�4� . Foundation .-�-.'....... Property Line ..T......•••..... <br /> SEEPAGE PIT [ ] Depth ;.__.��._--- Diameter ,.z.. I.�Number ----qO..........+_� Rock Filled Yes �No �Q <br /> Water Table Depth --------- .... --• -••Rock SUi <br /> a <br /> Distance to nearest: Well .... !r 0---. .............Foundation .fes-� �.. Prop. Line ...�....�... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........•-•............... 1 <br /> ' 1r+, 4 <br /> Septic Tank (Specify Requirements). •-•....••........... <br /> Disposal Field (Specify Re4u`Oements) ---------• ..........I..................... <br /> --- <br /> ------------------------------------------------------------ --- -------------------------- ---------------------- ............................. <br /> - <br /> ----------------•---...-----------------------------------------------------. .... ---_----------- <br /> .. # <br /> (Draw existing and required addition;on�reverse side) yy <br /> I hereby certify that { have pr pared 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 Son Joaquin Local Heolth.District!Home owner or licen- <br /> sed agents signature certifies the following: _t <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 ibecon <br /> ,WV61ect to Wgrkman's ompensation laws of California <br /> i <br /> Signed - ---- - - ------------r5 ....... Owner _ <br /> By <br /> B -C�----- ---- ----- ----- ----- ----- - --...... .......... <br /> �: Title :�� B-C.J -;_. <br /> (if other•t an owner) <br /> FOR 'DEPARTMENT USE ONLY ? <br /> APPLICATION ACCEPTED BY -------- <br /> ----- � R= ---=---------------------- DATE :_..cJ `- - --`--f..�----------.: <br /> BUILDING PERMIT ISSUED --• --------------- . ---.�i -iJ . ... -•--. ------ ....::.: DATE <br /> ADDITIONALCOMMENTS --------- •--••--•--•-_--------- ----------- ..................----------- --------------------------- ................. ........ --------- <br /> ----------- -----• --- - --------•---•------•--- -----157--17­------------------------------------ -- ----------------------------------------•---.---....-----•--- <br /> --- ---- ------------ -• -•------ --------•-- -----•-----•- <br /> ----- ------- --- - - --- --- i)ate �� _ <br /> ........ . <br /> final Inspection by: . � ••------- _..---•- ..... .. ---.../..._............................------ <br /> EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />