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1p_ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ----------------- -------------------------------- p(Com l�te in Triplicate) <br />--- ------------- ----------------------- - ------------- Date Issued <br /> ------------------------------ - - -------- <br /> This Permit Expire ll 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 I <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> C _ <br /> _ ----- CENSUS TRACT ...... -!.- -------- . <br /> i <br /> JOB ADDRESS/LOCATION <br /> Owner's Name ---------CE <br /> _.______ - - <br /> Pho e <br /> Address .---- : - '} - V/ — -SD- - ---------- City . r�_� L- <br /> i �V�L\` _r __ __.License # --------- Phone --------- ----- <br /> -----_------ <br /> Contractor's Name.: f <br /> 1 Z <br /> Installation will serve: --,:o Residence 5&Apartment House[] Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> r ,w,// & � 14�-F- <br /> Number of living`units:-__-__ __ <br /> __ Number of bedrooms ____Garbage Grinder /y_�---- Lot Size .___ _ __ - -- <br /> :_. ____Private P' <br /> Water Su.PPIy: Public 5yste`m and name ---------------------------°---------------------------------•- ----11--------------------------------- <br /> f I 1 Peat❑ Sand Loam Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Y � <br /> t Harpan`0__ ..Adobe ❑ ..;Fill Matel F if yes,type <br /> ; + ' <br /> (Plot plan, showing size of lot, locatio� of sy tem in relation to wells, buildings, etc. must be placed on reverse side.) \ <br /> NEW INSTALLATION:� ,) <br /> iNo septic tank or see ge pit permitted if public sewer is available within 200 feet <br /> PACKAGE TREATMENT [ ] SEPTIC TANK, ] �-4-Size-----------s-------------------- - Liquid Depth --------------------. <br /> p Y - -------- '�-- P Mat nal-- ---------- -- -- No. Compartments ------ -_----------- <br /> p{ Ca acit e <br /> Distance to nearest: ell ----- ---- - - - ---- - -- - -------Foundation _ -- _ - - - ---- Prop. Line .-----------...------- <br /> _, i ---------------------------- <br /> ine <br /> Length[ ] No., of Lines ___-------� -------.Length,of4each (line______------------ -- - --- Total Length <br /> G 'D' ,Box -----------_.Type ,iter Material ------------- -----Depth Filte Material ---------------------------------- <br /> t <br /> t } ., , t <br /> 1`. .� Dis#ante to nearest: W 1! `---------------- Foundation -----___--- Property Line -------------•---------- <br /> SEEPAGE?IT �.`.] �; Depth ___ Di meter ___._-_--_`_. Number Rock Filled Yes ❑ No I[j n <br /> � Water Table Depth ----- ------------------------------------------RockSize ----------- ------------•--- <br /> Distance to nearest: 1) -------------------� Foundatio Prop. Line <br /> r„ t . Date -1. <br /> REPAIRYADDITION.(Prev. Sanitation Permit# ..__ -- ----------------------- - <br /> Se tic Tank (Specify Requirements) -----------------�------------- <br /> _f' <br /> - 4 <br /> Disposol Field '(Specify:Requirements) -/1f _ -' ----- <br /> I JCl �'1l�{�G•-� -- 1^,f--�➢-�---„`--------//V_—IM-1-4------------- )--- A9K /�A_G�-� �1 <br /> ' _ S - ------------------- ----------------------___ ---------- . ---_---- ------- ------ <br /> f Fzl�= � ' t �, ------- ---- , <br /> f (Draw existing and required addition on reverse side) <br /> application and that the work will be done in accordance with San Joaquin <br /> I hereby certify,th�t,`I ha�e prepared this app ' <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- E <br /> sed-agents signature certifies the following: ` <br /> "I,certify t ' .{the erfor`mance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to�be o ubiec to r an's Compensation laws of California." <br /> Signed' ------- Owner <br /> BY ------------- <br /> ` I ri-P'_0----- Title ----------- ----------------- <br /> (If-other than owner) I <br /> 'i FOR DEPARTMENT USE ONLY <br /> DATE ------- W <br /> -- <br /> APPLICATION ACCEPTED BY --------�- , ------ - <br /> ------- ----- ---------- ---------- <br /> ' BUILDING PERMlT,.JSSIEE[7„.;r__>w:<- _ .,_. _ _ DATE ---_..�_- ., �v, _ <br /> - - <br /> ADDITIONAL COMMEV___ _ ---- -- -- ---------- ------------------------------------------------------- <br /> �f A_, - <br /> ------- <br /> _ 4__= �...__._ ---------------------------------------------------- ---------- <br /> -- - ,/ <br /> �------ --------------- ---- <br /> r Final.Inspectio = ate _._. <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G u 0 1_'AA Rate .TIM <br />