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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> iCompleto in Triplicate) <br /> Permit No: . . i <br /> ....................................................... <br /> -;Date Issued <br /> ....................................... This Permit Expires I Yeat From Date Issued x .. <br /> Application is hereby made to the.Son 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: 1 <br /> JOB ADDRESS/LOCATION ,� _. ►_lf.._1�'r...��C�. �"Oh.7l Ems...................._.......CENSUS TRACT .................... <br /> Owner's Name -...xel f� ...... - ---•-- --- ................................---.Phone .................................... <br /> Address ......N5Pr..............................................•--.......-•---........... City�. �� �...................a..............4......... <br /> Contractor's Name .....-�,c. .................................License #vVl"► r.3 _. Phone/ <br /> Installation will serve: Residence P(Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............... ............................ <br /> Number of living units:.../...___ Number of bedrooms ...Garbage Grinder/1W... Lot Size v?j0G'9�...................... <br /> Water Supply: Public System and name .............--..-_--.-.----•--...-..---._......._....___._......_...---...._._.___._....._..._._......._....PrivoteA' <br /> Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ JFlli Material _...___.__ If yes, type ---------------------------- <br /> (Plot <br /> ------------ -----.(Piot 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ Size------------------------ ••----------_ Liquid Depth ..__...... ............... <br /> i� i <br /> Capacity .................... Type ..._._..._.. ........ Material.---••---:__--._-._. No. Compartments .................:....� f <br /> Distance to nearest: Well <br /> ....................................Foundation ...................... Prop. Line ....:................. <br /> � I <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line.................. Total Length ............................ <br /> r` 'D' Box Type Filter Material ...Depth Filter Material <br /> Distance to nearest: Well .....:.................. Foundation ..._.-_...:.......__.__. PropeLine <br /> SEEPAGE= PIT [ 7 Depth ....... Diameter Number _----------------------;...- Rock Filled rYes 0No ❑ <br /> 1 Water Table Depth .....Rock Size I <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ................... r <br /> REPAIR/ADDITION(Prev, Sanitation Permit#!�.., ..-•...............•--...:........... Date _........_.__.....••............_.� —0 i <br /> Septic Tank (Specify Requirements) .................. - J <br /> Disposal Fi (Specify Requirements/ .. °. +tl.Q .f& ---- - f .........�,�. ���. . ../..1 ........ <br /> .. --------_.... <br /> _......_..--•--•-------------•---------------- ._._......._....._._...... _.. . --- . •--------------------••----•------------------------------------------------- --•------------- <br /> (Draw 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 San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifiesll16 following: <br /> "I certify that in the performance of the work for which this permit is issued, iI shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed F• ' <br /> g ---------------------•._......._ Owner <br /> B - Title L—;, 9�� � c'.a...................................... <br /> Y .__.................. `.._. --- <br /> (If of han owner) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........ ...... -"..,.::�...:.. DATE .... ��.` .._.. ._..... <br /> BUILDING PERMIT ISSUED ..._.....•--_. _ DATE -----•.............. <br /> .........................t.....__......_._........ .. ..._....... <br /> ADDITIONALCOMMENTS .............................................................•-•---• •--- .............._.....------------................------------------. <br /> ——---------------L......................­­......................... .......................................... .................­ .. ........ <br /> ----------------------------------------- .. ............................. <br /> .. ....••. <br /> Final inspection by- ............... :. - - ................................Date ,.. _Xi <br /> _ _r SAN.,JOAQUIN -LOCAL HEALTH DISTRICT <br /> 1.3 24 7 17,) 1 V I <br />