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POR OFFICE USE: APPLICATION FOR SANITATION PERMIT a <br />..... :. .�?�..7.................. Permit No. ..7.a...... 2 z. <br /> .... ? IContptate in Triplicatol <br />......................................................... This PennitExpires i Year From Watolssued <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 <br /> In compliance with County Ordinance No. 549 and existing Rules and Regulatlons: <br /> .JOB ADDRESS/LOCATi ..... . ..... . ....... 1. a........... ............CENSUS TRACT ....................... .. � <br /> ` w .Owner's ........... •Ph ne ..........................,......... <br /> Addressi.....-.... �. tY' ............................... <br /> g .a `�'�. .,�et!!.rLioensec rferlf•• Phone .............................. <br /> Contractor's Nam� ..... <br /> Installation will serves Residence Apartment House(] Commercial(]Trailer Court Q <br /> Motel❑Other---•........................................f k , r <br /> Number of living unitso.. _--...._ Number of bedro ms .. _...Garbag Grinder .. Lot SIze .. .. ..................... <br /> Water Supply: P%l'lIc System and name .J� ......4 ....................•Prlvc" 1n <br /> Character of soil tote depth of 3 feet: Sand O Sllt Q CloV-Q Pea o ,Sandy Loam ❑ day Loam Q <br /> 1 ,Hardpan 0 AdobeX Fill MQterlal ye ,typo <br /> f if s ............... ............ <br /> (Plot plan, showing size of lot; locotlai•-of ystern In relation to wells, buildings, etc.-'must be placed an reverse stclo.) <br /> NEW INSTALLATION: (No septic tank or,seepafge pit permitted if public,e er is avai`iabi'within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANK U Size�•�..r- ,e .., ./O.-E ... . Liquid Depth ... ................. <br /> Capocify� ` ,�T �aterial b No. Compartments ..c;Z............... <br /> ! Distance to nearest: We ........... Prop. Line .�--•---------. <br /> LEACHING LIN No."W. Lines _.:.._ ..___....-.. Length of a line... . . :::. :Total Length .,1 .-.�••--••••• <br /> ° ="i?'+i3ox -^ •- Type Fitter Material ..Depth fills►_ Material .................................. <br /> Distance to nearest: Well .l I.G.. ....... Foundatlon�.::..��..:: ...... Property Line --..•... ..... <br /> 10 <br /> c> ► ..._.... Diameter . f .. Number . .... .. ... Rock Filled Yes. � No Q <br /> SEEPAGE`PIT � Depth �-• - <br /> - �Waler Tabta-Depth Q`.................... .........Rock`-Size-�.�. ..f............_ <br /> Distance to nearest: Wel! . - ........Foundation ......... Prop. line ...: ---•,--__ <br /> REPAIR/ADDITION{Prov. Sanitation Permit# ............................................ Date ..........:....................... <br /> � <br /> Septic Tank,(Spedfy Requlrements) . .............................h.: .. ....x.. ................... ............................ ........_._..................... <br /> Disposal Field (Specify : <br /> Requirements) .............................. .. ..................... .F ._......�......................__............................ <br /> ,, "� <br /> ..{. 4_...... ... .__.:. ---".....�................ ...._....:................................. .... . <br /> ............ <br /> t Draw exists and re uired'addition on reverse iidel i <br /> I hereby cortlfy that I have prepared this application and `#hat the`work will be done in accordance with San Joaquin <br /> County Ordinates, State Lave, and Rules and Regulations of the San Joaquin Local Health District. Honte,owner or titan• � <br /> sed agents signature certifies the fallowing: <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 becomesub(ect to Workman's Compensation laws of California." , <br /> Signed _ .......... ..--- ...................... nerner'. <br /> By .......... ...... "�:�,;-• ..................•........ Xitle ......._Lr . .... . . <br /> .�� . <br /> r (if other than owner! i T <br /> . ...,,. .• _ - R_DEPARTMENT_USE-_ONLY <br /> APPLICATION ACCEPTED BY ....- .... ...... <br /> -� - :.........::.. ................................................ DATE <br /> _ . _. -- _ = �.. . ._ _ .�. ....3� .... <br /> ``:DATE ~- <br /> i3UILDING PERMIT iSSUED ..:.• ---- -•... .................................... .......................-....- .. " ....;,.. <br /> ADDITIONAL COMMENTS ......... ... ......--•-••............. <br /> .......................... ........... ......I.•... ..'1 -....... ............................ .......................-----••.................... <br /> ............................ ..................................................................._... -..............................................-......-.-.... <br /> ................................................................. <br /> .... <br /> ...-...... --.._.-... <br /> .. <br /> Final inspection by: - -.. ._ ---- Date .. T�..7 rel ......-.. <br /> EH 13 24 1-68Rev. 5MSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> J � . <br />