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FOR OFFICE USE- <br /> ................... <br /> SE: <br /> APPLICATION FOR SANITATION PERMIT <br />......-• -- . ...................... Permit No. ....7�'�.. <br /> (Complete in Triplicate) <br /> Dare Issued ...� <br />........................................................ This Permit Expires 1 Year From Date Issued ' <br /> Application is hereby made o the San Joaquin Local Health District for a permit t�construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 aAd existing Rules and Regulations: <br /> JOB ADDRESS LOCA O ..-s _ ..........:.CENSUS TRACT .........................: <br /> / _ � <br /> �wner's Name. �4. ........... ter....:..... Phone9/6^ �.' � ....... <br /> } <br /> Address . .. `� - J y ........ c► 4 <br /> .... . - ----- -•-• .............................. cit �.--------..� ....... ........ <br /> Contractor's Name .................... <br /> �(�.r�� ...License #� r7 y - Phone ._ ......... <br /> .` ....-4-... ----------• <br /> d7 <br /> Installation will serve: ResidenceApartment House Commercial ❑Trailer Court a 1 <br /> Motel ❑Other -----------...................:.............. <br /> Number of living units.---------__ Number_.of bedroomsy...........Garbag-e Grinder ------------ Lot Size .......................... <br /> .................. <br /> Private Supply: Public System land name ............................... _-J-----------­---------...........-----------.._..........-----•-- N <br /> Character•of soil to a clepth of-Wfeet: -Sa`rffd]] =5ilt Q`"aClay [3Peat[ - Sandy-Loom-,K—Cloy-loam Q-- - <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ <br /> �� x " t <br /> (Plat`p.Ean,+sewing size of lot, location of relation to waifs,, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permit'ed ifrPublic sewer ilavailable within 200 feet,j `r h <br /> PACKAGE TREATM w y <br /> x <br /> ENT;,,�� �SEPTIC TAMC, ] Siae..�.�...---�--�.... .................... Liquid Depth --- ........--------.-•--- <br /> Capacity C} 1.. .--- --.. Type . ............. ..l Material--- ..... Na. Compartments F' ...i.......... <br /> Dist nce�to nearest: Well ........ :9'D._...........Foundation ...1b---`f-_---- Prop. Line _. V "....... <br /> t. ,. rT r/ <br /> LEACHING LINE No. o Lines <br /> engt�f ea line._ V ... Total Length ._.�:...l............ <br /> 'D' Box ............. Type Filter Material <br /> � . . ..... .......Depth Fiitir Material ---Id'..-•.� .........-•-....... <br /> Distance to�nearest- Well ....................... Foundation ....... ` .......... Property Line ----------------•....... <br /> SEEPAGE PIT [ J Depth Diameter______________ Number --._______ ------- Rock(Fill d Yes ❑ No C3 <br /> • Water Table.Depth .. ................. <br /> I <br /> Distance toy nearest: Well ..................... <br /> ..................Foundation t.. 's._-.......... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation;Permit # -_-----_----------------- . ---.-- •--•-• <br /> 't Septic Tank {S eci Requirements) ..................._...------..---..... - { <br /> w . ....... <br /> -,-- <br /> Disposal Field (Specify Requirements) .............................. <br />�.. ........................------ : --------• : ......-------_---------- ••• . _ ----------- .....- - �:-� .�� <br /> ---------------------------- ------------------------------ <br /> ----------------- --------------------------- ---.:�........__._._......: _.........---------..._........... <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 signaturecertifies the following. <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 became subject to Workman's Compensation laws of California." <br /> Signed ...................... +. . ......... ..........:........................_.. Owner <br /> By ............... -`... •----------._.....--••-•............. Title .......... .......................................... <br /> (If at , an owner) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED,. 8Y ... --._. . .. . .........................................I................:.. --....:.. DATE ..•...... '�. �.�-- ............ <br /> BUILDINGPERMIT ISSUE:D,. ......-•••----•................................................................................DATE ._.......... ................... --------- <br /> ADDITIONALCOMMENTS .................................................................._-----------._.....................----•-------.._...... .._...� <br /> ..................................•------•-••--.--.-.. .._.. -----------------._._....... --•--._....-- --.....-----------...._.#--..---•-•-••------------- ...............------.......:.... <br /> l;. t •. ......... ............. <br /> ------------------- --- ------------ --- -- •.. y.� <br /> r ..... .... :. ................ . ....................... <br /> M Final Inspection by: ---••- ........•••--- �.�. ..... .......Date 1 <br /> SAN JOAQUIN �LOCAL •HEALTH DISTRICT r <br /> F u 13 24 _ 72-3 M <br />