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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION: PERM.......................................... IT7 96 <br /> ' Permit No. .. .......... <br /> IComplete in Triplicate) <br />..................................................... Date Issued <br /> ..................................................... This Permit Expires 1 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/LOCATION _.>� Q. .....nF=1 .M. v9.?q..............................CENSUS TRACT <br /> Owner's Name ...... .. .�. -p .....:..:..:..:. .:..:..: ..:.:.:...:� .Phone ...._..._....._................ <br /> Address ...... �.�.. ...-..r.�. ' ... .�/.Ra.D.....[?. ...."Cif) .. �[` C- ................. <br /> . <br /> Contractor's Name ............dI11R.N .:...:....................:..::...::.::..License # ....... .:..--------. Phone .............................. <br /> Installation will server Residence T`X'partment House 0 Commercial QTrailer Court 0 � <br /> r >� �t <br /> Motel`[]Other ...........�: .:....::....:.....:...::...... <br /> Number f livin unit :.. : .-:.----i�l m # + r <br /> g s u ber-of-bedrooms ._.___Garbage.Grinder ._, Lot Size ._tVAe< 4 �I _..__.._... f <br /> Water Supply: Public Syst m,on8 name .................._ .._ _ ...........................-� Private"[ - <br /> Charactersof soil to a depth of 3 feet:_ p! Sand.Q Silt Clay ❑ Peat Sandy loam.0 Clay loam$9'f <br /> v.gyp Ems, 11-- <br /> Hardpan Q T Adobe'Q FIII Material - ... If yes,type ............................ ,Q <br /> (Plot )plan, showing size of."lot,—I"o'Cc ion`of-syst6m,-I i-relat'ion to,wells,,buildings, etc. must be..plpced. on'.reverse side.) <br /> F . R'; <br /> NEW;INS ALLATION: ,IN'o septic tank'orfiseepa pit permitted if public sewer is available within;200 feet,) <br /> -- --4 <br /> i!t <br /> PACK4GE TREATMENT [1]: SEPTIC TANK Size.._. .........................© X � ..._ Liquid Depth ...... <br /> _ ........... . _.. <br /> 'C4pc'c'ty <br /> . .I ... Type PI�CCR.5.l. Material.!;P! �.T No. Compartments .....rte....``. ..... <br /> Distance to n'earest: Well` .....�4�Q "'...........Foundation ...f..�..�:::.:-Pro p:Line"-... .... <br /> .. <br /> LEACHING lIN>: [ No, of lines?::. �..�....._.._.:. length of each line....................:?�:.... Total Length <br /> s© <br /> 5 T r� --• <br /> 'D' Box � e Filter Material ��:�:K..De th F I r �afierlal .....:../ q <br /> . Foundation //ss�� <br /> Distance to nearest: Well .....�Q..Q._ !4�_ r�:.._... Property Line ... _ <br /> SEEPAI [ 1 p r ia e ��C..� .�.�..:�:Number - --•-•- •o (:3 <br /> GE[IT Depth th ..._.[�,,-��.,,.,,-...��. .�5iameter .:::-:.:.1.....:.. .:.... hock Filled Yes �No <br /> Writer Tabl6'� epth ... .,�r�� r... ............ .Rock Size . . Z... �K <br /> �_{r c <br /> tt i t <br /> Dlstarite.to.nearest: Well �� Foundati n Prop Line . <br /> ' ......t..... .... <br /> .. .... <br /> ... . . ..... <br /> I � k <br /> REPAIR/ADDITION(Previs Sanitation Permit�# ....:...... .... :..........:............ Date ...................... ......:.:f <br /> Septic Tank (Specify Requirements] .� :.._.... - ....... ...... ?°....................... .............. <br /> Disposal Field {specifyR quirements) ..__... .........................._ ...... <br /> .............................:........ <br /> ..... " .......-"......".... ...... ....e: ,. ... ............................... .................................................. <br /> ' ` {Draw existing`and�requiirred 'addition on reverse side) <br /> I here bycertify 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'Regulation`s oft Joaquin Local Health District. Home owner or lic*w <br /> sed agents signature certifies the followings . <br /> "i certify'fh the erfor ante. the work"for which thls p-errnit Is,Issued, I shall not employ any person in such manner <br /> as to beia ubje to orkma Compensation lows�of Cdlifor�la."� <br /> Signe .. .. <br /> g - Owner <br /> By ..-.. ::.............•-•• .e."10 <br /> ................ 1 1. _. Title .: :..........:..............:..................... <br /> :................. <br /> (If other than owner) <br /> FOR DEPARTMENT 115E ONLI <br /> APPLICATION ACCEPTED BY .....--�1.-- ..r'''� ......................:....., DATE :./o zl .. .....s..., <br /> 1 <br /> BUILDING PERMIT ISSUED •t ......••••••-•-•.....................................:.......................DATE ...........{;� ......... ....... ..... <br /> ............:....... <br /> ADDITIONALCOMMENTS ............. .................. . ............ •••. . •----•------•-••-••••.....••••-•-•...•••---•--..--•-•-••..............._.... ------------- <br /> ....... .. ?: .�..................47'-w-. X: .............. ... <br /> :--:.-•.. :::... �• !' .•........•--.•• <br /> :n . ' .... .. .....`°mow. ,- .....I................ ....r�� ..... � <br /> "Final inspectiarrbyy C�ti:1t� .Date.... '!.._.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241'.'68 Rev. 5M 7/72 3 M <br />