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FOR OFFICE USE. <br /> APPLICATION FOR,SANITATION PERMIT <br /> Permit No. <br /> (Complete.iit Triplicate) <br /> Z <br /> This Permit Expires I Year From Date Issued Date <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 /> t JOBADDRESS/LO ATION .....�.. - ... ..5.•.---. .... .I.'�� 'E h 4 K.-.... .� r� P .� CENSUS TRACT <br /> .... ......... ..... <br /> Owner's Name . . `I�� f .. �.. _. ..... .....Phone .. <br /> [Address ... .,..,. ..... -� .`7.......J,ff,----)<eA.CAor. ..--•-••• City .._.�..►..��?��........................ .............. <br /> ' Contractor's Name ..t.�p.` ..... a .e.S�-,................................ <br /> �`' r License Phone <br /> Installation will serve: _ Residence 04-Apartment Clouse 0 Commercial❑Trailer Court ❑ <br /> Motel ❑Other .......... •---- <br /> Number of living units:_..._.�...._i Number of bedrooms .........Garbage Grinder/ <br /> r.'.. Lot Size ...�.. p.. `' <br /> Water Supply: Public Systemandname ________________ .._ ....Private <br /> Character of soil to a depth of 3 #eet _,Sand❑ Silt❑ Clay ❑ Peat 0`, Sandy Loam C] Clay Loam X <br /> Hardpan Adobe❑ Fill Material .............If yes,type <br /> (Plot plan, showing .� f <br /> p g size of lot; location of system in relation to wells, buildings;retc. must be placed on reverse side.} v` <br /> ' NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,J <br /> PACKAGE TREATMENT [ ] -SEPTIC TANK Size.-..'YK.S--X­;_ ............... Liquid Depth ..*�� <br /> Capacity ..... Type !' Materiala,%-.. , __. No. Compartments ...Z..............% <br /> Distance to nearest: Well _..._€. .{-----------------•...Foundation ...16.............. Prop. Line __.._ __._. <br /> x r <br /> LEACHING LINE [��ko. of Lines­_.".-p�................. Length of each line._.. f--.7 ..._. Total Length ................... <br /> 'D' Box y eA-... Type-Filter Material .........Depth .Filter Material .Jef.... <br /> Distance to 'nearest:•Well --_ ------ Foundation I.....__ Property � <br /> ---._._..... Pro a line ...�........__....._:.� <br /> i . <br /> I SEEPAGE PIT {yJ� t Depth yzr_�_... Diameter .... �'.��: Number .__....... ... Rock Filled Yes No i❑ <br /> ► Water Table Deptft ---.-------.................... .....Rock Size.-.:. . ... . ........... .. . ..3 <br /> Distance-ti) Well•... ". _.. <br /> . .... Prop. line ............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...........................................• Date ................-_°+_.............. <br /> } <br /> septic Tank {Specify R'equirements) -------....................................................... ..............._.............................................................. <br /> Disposal field ISpecify Requirements) ................ ..........................................----------------- '-_---------...----------------------I......_......- <br /> -- <br /> ---------------•---•--- <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;Locai Health,,District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the perforniance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.,, /;F <br /> Signed -----------•---- caner <br /> --------------�------ <br /> By ------------- / -A---- -_ Title ..... <br /> _•--- . : <br /> If o er=n owrerJ <br /> FOR DEPARTMENT-Lig ONLY _ <br /> APPLICATION ACCEPTED BY . 7, --•- _ ,- ...�C/��-- [SATE <br /> BUILDING PERMIT ISSUED _.. i--- ------- -- --------------------------- DATE .... <br /> ADDITIONAL COMMENTS ---------`•-- •-------i---.--- • - <br /> ----- ---•- .----------•-----•---- <br /> rs E tl, a- t% <br /> --- -- . <br /> Final Inspection by: ..--- •- --•----... -_--_-------•.- .........................Date �- �_�_.�._ .....-_....� <br /> f EH 13 2� 1=68 Rev, 5M <br /> { S 4 SAN JOAQUI LOCAL HEALTH DISTRICT 8/7h M <br />