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FOR OFFICE USE: <br /> APPLICATION,.FOR SANITATION PERMIT <br />............. <br /> ................. ------. �S <br /> Momplete in Triplicate] <br /> Permit No. .7�..._._....-_ <br />_....... 9,-y 7y <br />...............................................••---..... This Permit Expires 1 Year From Date issued <br /> Date Issued ..........._I...... <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 on existing Rules and Regulations: <br /> JOBADDRESS/LOCATION .... .. _ .'Z�'�._.. d..__ .Dr►!_C~. �' .-.. .............CENSUS TRACT ........,...._..-•----.--- <br /> Owner's Name ......... ..�.r?�c�L' ._...� <br /> ........... .. --•-- -..._...--------....,---------------=-.----•----•--•------Phone <br /> Address .......... -�� ' • .../.�j ..... la.: N. .. ........ City ..ZeaeC �4t ----...---•--------------•-•-----••---•-•-••--••---... <br /> Contractor's Name ...... ....._._ _.....License # ............... .. Phone ................. <br /> Installation will serve: Residence M-6-cirtment House❑ Commercial❑Trailer Court' o <br /> Motel ❑Other ....................................... <br /> Number of living units:..../_----- Number of bedrooms ............Garbage Grinder ------------ Lot Size ............ <br /> Water Supply: Public System and name .--------•...................•--------------------------....----------------------------------------------•-.Private N <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ----------------_____ <br /> {Piot plan, showing size of lot, location 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 TANK( ] Size___........-------------------- Liquid Depth .......................... <br /> Capacity ......... .......... Type .................... Material...................... No. Compartments ._..._..._ ........... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line............................ Total Length ............................ <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation .................. Property Line ............... -------- <br /> SEEPAGE PIT [ ) Depth .................... Diameter ... Number............................. Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ..................Rock Size <br /> Distance to nearest: Well ........................................Foundation ..._--___ -_ ---.-- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> Septic Tank (Specify Requirements) ........ ./ ._ / .......................... <br /> Disposal Field (Specify Req irements) ..�j� G�r� ..�rzsvc l .__ p__ ���1- ....... <br /> -------------•-•-•--•---._..__....._.i .....T......-- ._-•---.........................I.....•-•---------• .... <br /> ..............................................................I......... ----------- <br /> .......... --•-----------------------------•----•--._.... ..I—------I—............... ------.. ..------------------------------------------...--------....._..----.._...-------------_._.. <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify 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 Regulations of the San Joaquin Local Health District. !Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed X. Owner <br /> By ...................................... _......---------------•_..........-----•--........ Title ------------------•-••-----------------•------------..._...._.._------.. <br /> (If other than owner) <br /> FP R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- _._.. .................................................... DATE ..._.`�T'.l- "7X-•-- <br /> BUILDING PERMIT ISSUED ................................ .......................................................DATE <br /> ADDITIONALCOMMENTS ...........................................................................................................•............................................................. <br /> •---•-------•----------------•-----------• ._._....__..__..... ........-----...__.._..----------------------------------------------................ .................... <br /> ............I.............I......... •. ... ........._.._. <br /> - - -•---•--•----••--•-•---.-... .... <br /> Final inspection by: ................ •-- ---...............................--........Date .._ `�....y�.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 13 241-'b8 Rev.5W_ — - _x"7-/-.72 3 M <br />