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e <br /> FO FFf CE USE: -� <br /> 11 APPLICATION -FOR SANITATION PERMIT 6 <br /> ..._. .1�.....-�9 ...................... Permit No. .............. <br /> .. . <br /> (Complete in Triplicate) 3 <br /> .................................. This Permit Expires 1 Year From Dote issued date issued . .././`�3.. <br /> i4 <br /> Application is hereby made to the San Joaquin,4ccol HegIth.DJstrict for a-"permitrto construct and`wi'nstall the work herein <br /> described, This application is made in complicince'•withIC6u'nty Orclinq;ci--No."544�and existing Rules and Regulations: <br /> Y� <br /> JOB ADDRESS/LOC TION ...:.......... c�.... CENSUS TRACY <br /> Owner's Name .. _k ... j �.t.. t�✓ ?. ... ........................... .. . ....... _.Phone ------•---�.................--- <br /> .: ... ....................... <br /> Address .........•------ - -,�t�.� _ ............ City - -... __......... ...- .. ....................... <br /> Contractor's Name... ---=------------ • ....................License ... Phone ..�.-�-•- --...._. <br /> Installation will serve: Residence 44artmiexnt House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other Z :............:....: : �...... . <br /> Number of living units:_.._._... Number of bedrooms .. ....Garbage Gr der.._!f._!.._.. Lot Size ............................................ <br /> Water Supply: Public System:and name = - ..--- . ........_.-•--- ....................... <br /> Private �� r <br /> Character of soil to a depth of 3 feet: Sand Silt-[] . "Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ -Adobe'❑ Fill Material , .. If yes,type ............................ <br /> (Plot plan, showing size of lot, location of. system in' gelation to wells,,buildings, etc. must be placed on reverse side.[ <br /> NEW INSTALLATION: i <br /> {No septic tank or seepage, pit permitted If sewer is available within 200 feet)�/` <br /> PACKAGE TREATMENT ( ] SEPTIC TANK] ..# N e-__.... _5.................. Liquid Depth 7"1 .......--•---- <br /> Capacity :.. Type Materia[_ _... No. Compartments _ -J_.__.......: <br /> -- <br /> J QV <br /> Distance to nearest: Well` - ...Foundation f�� Prop..Line ...,i� .........- <br /> LEACHING LINE [ No. of Lines ..__....f:............. Length ;�18<h <br /> ach line-----: .-----.-.------ Total- Length ...0.1.............. <br /> { bi i <br /> 'D' Box _._ Type Filter Material :...--Depth�Fiiter Material .. .,�.�......................:...:..... <br /> Dist_anceuto nearest:;Well SR.............. Foundation -.Pe _ Property Line t�J <br /> SEEPAGE PIT De thf ❑ <br /> { ) P �...............•:__-- Diameter ......_......... Number ...._-____..._..- ._._..... Rock Filled Yes No <br /> .Water.'Table Depth <br /> Distance:tonearest: Well ............................:....... :..Foundation .................... Prop. Line ........ ............. R <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......._-----------......................... Date .................. -----_-_----- <br /> Septic Tank (Specify requirements) ..........................;---- ---f----_ ..................:....._....__ ..........._...............-- <br /> Dispasa Field (Specif Requi ements) _------------ <br /> °Y , ._ <br /> 3 <br /> (Draw existing and required addition-on reverse side) t <br /> I hereby certify that I have prepared this appii_cation'and that the work will be done in accordance with Son Joaquin <br /> k" County Ordinances, State Laws, and Rules and Regulations of the 'San Local Health District. Nome owner or Iicen- <br /> sed agents signature certifies 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 become subject to Workman's Compensation laws of California." <br /> Signed ............................... ...... . --_. Ownera/. ,_+ _By •.....................•----•------ . ._ ..._ .---. .. .............. title _.._ `"`�-:-'�v_.._....__.....__._...: <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Vi .. DATE �_�.'.�� ...:............. <br /> BUILDING PERMIT ISSUED ..::. .. .:...:....:...... ............:......... .....DATE ....._._ .............. -..._----_------- <br /> ADDITIONAL COMMENTS ------------------------------ ......................................................... <br /> --------------------------- <br /> ..............................................I.._._.... .---. .......---- ----•-----..._...._.. ... --•--•--------------------.--._...:._...................................._..._...__.... ... <br /> -----•------• ------ ------- ------------.. :.. :. ........_ ......... ............................................................. ............... ...... <br /> Final Inspection by Date .. r .-• <br /> ..................... . <br /> JOA I-N LOCAL HEALTH DISTRICT <br /> E- N 13 24 t-'ba Re,,_ sM - w -- 7/723L <br />