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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..7.�.`:3.3 S" <br /> .................• ---.....---....-- (Complete in Triplicate) . <br />................_..:....._.........._._...._......__.... 3: �S– <br /> This Permit Expires 1,Year From Date Issued r� Date Issued .-.....J... <br /> Application is hereby made to the Scin 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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION !L.: ` '2 ,% <br /> .�._ ..-_._.�: - . 11._�'!�.(,(.�--� rd� ..........................CENSUS TRACT ..._.__........._.'._._... -. <br /> y .....Phone ....................... E <br /> Owner's Name .............�...._ 'ii._./.,�.-�'•/1:os`��.-------..._....----------••�-•----.....-------•--�---•......�� .......-----• <br /> Address ..-- = <br /> iW. I ;� 1­1 -. City .VrJ � lf/ _._... 4 <br /> .....--•-- <br /> II license # /.a�., 1-- Phone <br /> Contractor's Name ..../�G QAr <br /> jf�:`�/�t�, �'f/ -------------------- <br /> installation will serve: Residence pg Apartment House-❑ Commercial ❑Trailer Court 0 � I <br /> 1 • <br /> I / ? . Motel Other .....-- . �- • ------ <br /> Number of living units:.... -..._. Number of bedrooms �-..._.Garbage Grinder�/P..... Lot Size _% --�--' � <br /> Water Supply: Public System and name ....__-.--_---_.-- Private,( ] <br /> il <br /> Character of soil to a depth of 3 feeO Sand❑ Silt❑ Clay ❑ Peat . Sandy Loam Clay'Loom <br /> If yes, typeil"Hardpan E] Adobe X Fill Material ...._. :.... -.•---.'....,---. .---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc: must be placed on reverse side.) <br /> I <br /> NEW INSTALLATION: lNo septic; tank or seepage pit permitted if public sewer,is dvailable within 200 feet,) <br /> i :. <br /> PACKAGE TREATMENT ( ] SEPTIC TANK.1 1 Size.....-........•------_' -_----------- - -•-- Liquid Depth ........ ................ <br /> I .•._... No. Compartments .::.............. <br /> Capacity !- -- .....--•- Type -----•--•---•• •---- Material............: ..... <br /> Distance to nearest: Well . .......__..........:..........--Foundation ...................... Prop. fine .......---------..... <br /> I� .....--- ..._ Total Length ..._....---- _/ , <br /> LEACHING LINE O No. of Lines Length of each line .-_._ t <br /> D' Box . ? Type Filter Material -------V___..._.-Depth Filter Material ------------------.. --.----.. --.-- <br />} <br /> Distance to nearest: Well ................. .___. <br /> - Foundation ....................... Property Line ...._.......... ........ <br /> I� _ <br /> SEEPAGE PIT O Depth !,. .�. --- Diameter Number ---------- ----------------- Rock Filled Yes [D No (] <br /> Water Table Depth ----------._ _-----.-•-- ' ''............ <br /> ....--- •`-Rock Size _ ....................'. 1 <br /> Distance to`nearest: Well ........... .........------..---------Foundation..__-•-.,--,.n..:,..---- Prop. Line .............. -- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .---------- ------------ ------------ Date -------- 1 <br /> I I S <br /> Septic Tank (Specify Requirements) _..._... } W"=------_--------,w -...._..... .r.._..._.._... <br /> li 1 i /` <br /> *;Y Disposal Field; (Specify Requirements) a_dW ---g4a-•--Q, e., . .....---- <br /> - - ------ <br /> ..--------------- ---------------- ... <br /> 1`....(Drdw'exPping and required addition on reverse side) <br /> i II <br /> 1 hereby certify that i have prepared this a lication'rid that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of.the San Joaquin Local Health District. Horne owner or licen- <br /> sed agents signature certifies the foliowing: <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 ...... .... .....,_ .tth <br /> ._. .:.-� - Owner <br /> i By .... . Title �w�/ 1 . ............ <br /> (If owne FOR DEPARTMENT USE ONLY -,• <br /> APPLICATION ACCEPTED By . ..._ �--r.....— "I....... DATE <br /> BUILDING PERMIT ISSUED ------ "...... ....-- ----- .......... --------•--------------•- ------- . . - ----•-----.. ........................ <br /> ADDITIONAL COMMENTS ..._..._ '�._ _.. <br /> ..................................//.._..-0 .__"'._--_._"-.-.. ..._ ._.____.._.. ..._..._.--. ?..._ -......._._......_-....'..--'....-•... .'.•.-_••----.-,........ <br /> ................................................... --------------------I ..-. <br /> "II Yr <br /> Final Inspection by: _.. _..- c -------------------------•.---•-..._--------- -------------- .....Date ..yr _37. ......_..._.__._. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` <br /> 13 24 �N <br /> , •xo o_., caa 7 7 <br />