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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> E.......... ................................ Permit No. ....... <br /> a (Complete in Triplicate) <br /> .......................................................... <br /> .............................:.:..._...........__•--•_-.. This permit Expires i Year From Date Issued <br /> Date Issued ..7-:J.-�.t�.._. <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 in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....2G 1_._/. /%!l1G.. ...........................................-_...._..CENSUS TRACT ................. �...:.. <br /> 000, <br /> Owner's Name ._���- - �4� ._-----_ Phone _..._4`. '.7.........__ <br /> Address ../r�27 Lu •_ . tl ......... City _ ................................................. <br /> 3Cont � ............. <br /> ractor's Name � . . . -- ----- ---- ----------•---------•• License # ---.........---- <br /> ----� Phare ... <br /> Installation will serve: Residence ®'Apqrtment House-❑ Commercial Trailer Court ❑ <br /> Motel ❑Other . .........------- ------------------- <br /> ----- <br /> Number of living units:....../----- Number of bedrooms .....Garbage Grinder,._........... Lot Size ..._S ._?C./aC?............. <br /> Water Supply: Public System and name .----•....................._......_.....Private ❑ <br /> Y <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> i Hardpan ❑ Adobe j' Fill Material ---..------. If yes,type -- --__------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> I <br /> PACKAGE TREATMENT SEPTIC TANK -Qa.......................... Liquid Depth ..._...._...:_.__._....... <br /> Capacity-.4244-_-._ TypeG'4og/:;7 _ Material---------------------- No. Compartments ..__....._...........U) <br /> Distance to-FnearestX: Well . <br /> ---...._-•...............Foundation _.f�.�____..__. Prop. kine ..�-•---.•-•---... <br /> LEACHING LINE (.j No. of Lines _ g g <br /> Length of each line _-��-�. total Length <br /> l __,................ <br /> 'D' Box .._/. Type Filter Material /i......Depth Filter Material _._/.9.`P.......................... <br /> f <br /> Distance to nearest: Well ----------------------- Foundation lC?...__..._.......... Property Line -_'5---------:---.-._.- <br /> SEEPAGE PIT [ 1 Depth . 2 .r....--.. Diameter _ Number ................. Rock Filled Yes I✓� No 0 <br /> Water Table Depth ................... - --------t............_.-Rock Size ................................ <br /> - <br /> Distance to!nearest: Well ..........................._--------..-.Foundation ._._ .............. Prop. Line ......_..._.... ...... <br /> REPAIR/ADDITION(Prev. Sanitation!Permit# --------- ..........:..........6------------ Date -------................•-----.----} <br /> I <br /> SepticTank (Specify Requiremerits) .........___........................ ---------------------------------------------------- ............... ------ ---------------- <br /> DisposalField (Specify Requirements) --------------------- ----------------- -------------------------------------........---------------- ........-........................ <br /> f i <br /> ------------------------------------- -----------.....----------- ---- •-------------------------------- <br /> ------------------- <br /> ------------------------- <br /> .. --------- --........-----. ---------- - -----------------------------------..................................-----.....---...----.._.._ <br /> I (Drriw existing and required addition on reverse side) <br /> I 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 Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the rmance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become sub' rk 's Compensation laws of California." <br /> i <br /> Signed .:.. .....�. ..... . ..._......_.�:.................._......._.._:.._.......:_.__.._. Owner <br /> By .... ..... .......... ................................ ................. Title . <br /> (If other than owner) <br /> FOR DEPART)"NT US ONLY <br /> APPLICATION ACCEPTED BY ..- ............... -•- .. .....:.........................<.... DATE . .... .:. . ; <br /> t BUILDING PERMIT ISSUED ............. ...' .... ------- - ......._DATE ..--- ....--•-----........................... <br /> ' ADDITIONAL COMMENTS ...................--- ....................................................... ....... <br /> ..................... ------ ---•----•-----•------•---. ................ <br /> -----------------------._..-------.-� <br /> I Final Inspection by: IR- <br /> - -.- - ----._c_..... _. _Date �. . <br /> i t J ... ....... .. ........ T <br /> G - <br /> ;'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I c u 13 24, 'AD o_., cu 7/723 M <br />