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4FOR OFFICE USE: _ qhrr <br /> xAPPLICATION FOR SANITAT 1 PERMITPermit 4Zj3 <br /> No: ..................... <br /> s (Complete in Triplicate) <br /> C, 7S <br />� � Date Issued ................:... <br /> This Permit Expires 1 Year From Date Issued <br /> f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> j <br /> described. This application is.mode' in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> c� e vise �:c�C�' .._CENSUS TRACT .. . ....:........... <br /> JOB ADDRESS/LOCATION ... � I !Y_ .. �(/P............... .................. <br /> � - � sus .-- <br /> Owner's Name ........._/.�/.�...............��!.�'.?:-----.it!t:.........................----• --- <br /> .._..Phone <br /> Address .... - X....��.9��................. ........ City --4.4 11.'.P�..........._.....................--•---............ <br /> G�S <br /> Contractor's Name ..-94 j`dri/ S License # Phone .........................i <br /> Installation will serve: Residence ❑Apartment House❑ Commercial Vrailer Court } <br /> Motel ❑Other ---- --------------------------------------- <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ....._._.._. Lot Size .................................... <br /> Water Supply: Public System and name .........................................................-- .................................................Private <br /> Character of soil to a depth of 3 feet: Sand, . Slit El Clay ❑ Peat Sandy loam ❑ Clay loam El <br /> Hardpan ❑ Adobe❑ Fill Material ............ If yes,type --.--_---------------••— � <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r <br /> NEW INSTALLATION: {No septic;tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT ] SEPTIC TANK ] Size............ ----------9, <br /> --.?.- ................ liquid Depth _ .............. <br /> II <br /> Capacity ........ Type t't.�/�_�r. Material-.C�MCf...... No. Compartments ____ ....... <br /> Distance to nearest: Well -./0�'°..........................Foundation ._1A............. Prop. Line A .......••-•-- <br /> LEACHING LINE ( ] No. of Lines _---.__�............. Length ofppeachh.. line.__I�a .__,------_.: Total Length .SOP................. <br /> 'D' Box - ��___-- Type Filter Material !!a lb..-.-•-•Depth Filter Material ---- 0_�!---•-_-------------------- C <br /> Distance to nearest: Well .A?�!............. Foundation .......... Property Line ........_--.- <br /> SEEPAGE PIT [ ] Depth ............ - Diameter ................ Number .._--_------_-- <br /> ------- Rock Filled Yes ❑ No �] <br /> Water Table Depth ---------- •:..................:.. .........Rock Size ................................. <br /> Distance to nearest: Well .......................Foundation .___-_-.----.._...-- Prop. Line ...................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# ............................................ Date ...............------------------_I <br /> t <br /> Septic Tank (Specify Requirements) -------------------r_. ...... .-•................................................................7 <br /> Disposal Field (Specify Requirelments) •-•................ ---------------------• ----------------------------------------____---------...._.....----------... <br /> r -----•---• •------•--------------------- -••••------•. I -------- -------------------•-•------- -------...-------....-----.....-------••---•----•--------..._....-•--•-..._.--............... <br /> ...._. <br /> E_ --------- -•-- --- -• -------------..__.................• ....... ......................•....................I................ <br /> ._ <br /> I I (Draw existing and required addition on reverse side) <br /> r 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin v <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Lotal health District. Horne 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, I shall not employ any person in such manner v� <br /> as to become subject to Workman's Compensation,laws of California." <br /> Signed ._...�<--I!!'7Xe,1Y,� `� �h� <br /> .. ...............................:.......................... Owner <br /> .... jitle ---------•....... ........................................... <br /> s <br /> -FOR"DEPARTMENT USE ONLY <br /> G APPLICATION ACCEPTED BY .----- ---------- <br /> APPLICATION ........................:... DATE ...�t� A . ---. ---------... <br /> ---•- <br /> ' BUILDING PERMIT ISSUED .......- ...............................DATE ....... <br /> ......----.I..........--•------ <br /> ADDITIONAL COMMENTS - -----.......-•---•----•.............................................:................... <br /> .--••-------*...................... . <br /> fl <br /> t .............................. ............----------------• ..................................................-._.....Date ...._��:.Gx.l-: ................ <br /> -- •-- -• <br /> _ <br /> Final Inspection by: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r � n ' <br /> 11 24, •moo n_., caa 7/723.1 <br />