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FOR &FFICE USE: <br /> APPLICATION FOR SANITATION PEF'.41T <br /> (Complete in Triplicate) Permit No. <br /> -- This Permit Expires 1 Year From Date Issued Date Issued <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _.. �_g 1p_Q a /1J. at-V�/ 9 1 ,/�A,�9Aa (14Z , . <br /> ------- ------------------- - - - ---CENSUS TRACT `5�- <br /> Owner's Name �H� A R (302 - {{t,rj ,5� 'L}13 P•�� A?A7.Up <br /> --- -- <br /> Address ---1�-'-Q�---1�'---fl_.� .__p1,�.2 C�, <br /> �y�- ..... --------- ---------------------------- ........... <br /> City C�A�ccA 4.;/ 9 6a-1.. <br /> Contractor's Name Ado T!/1 ,/'1�1? _1"pRP_ �j �j'�4-1 my�'3l <br /> . 1 -----..License # ----------- --------._ Phone9 ?�1S'Z <br /> Installation will serve: Residence []Apartment House❑ Commercial 91frailer Court <br /> Motel ❑Other ---------------- <br /> ---------------------------- <br /> Number of living units:_1 6_0__ Number of bedrooms �2 dGarbage Grinder -__ __.. Lot Size ..__�"a__X_7 0 <br /> ' <br /> Water Supply: Public System and Home ------ !VA7 W-Gt. `S'/�2'f'.i_ t--- `¢l '8 rivate <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam Clay Loam [] <br /> Hardpan [❑ Adobe ❑ Fill Material ..-------- _ If yes,type ---------_---_-------- <br /> (Plot <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 /> PACKAGE TREATMENT TQt°+fli�t!U11— <br /> ��dK' R�A.w� Size ------------------------ Liquid Depth -----------------_-.--- ~ <br /> Capacity ---.-----..-------- Type -------------------- Material_Wl?eT+CG__ No. Compartments ---................... 1.4 <br /> Distance to nearest: Well _J__ ? __._____Foundation _eaE7i,t`laC�r�_ Prop. Line _X670 ---- � <br /> LEACHING LINE [ ] No. of Lines ---------- --- r <br /> ----___--- Length of each line--------�-,$a _-- Total Length -----�'��?---_-----_-- 13 <br /> 'D' Bax ---- - Type Filter Material PV ---------Depth Filter Material ---2? Q_.t.__ <br /> -.---•-------------- <br /> Distance to nearest: Well ________________ Foundation ___________._-_....__ Property Line -------------------­--- ItJ <br /> SEEPAGE PIT [ i Depth _..2 --------- Diameter ---------- Number -----------------------. <br /> Rock Filled Yes 2" No C <br /> - <br /> Water Table Depth -----�I 40-------�d---------------------Rock Size -� •�--------------- <br /> w <br /> Distance to nearest: Well ----- __KV...S_-_.__Foundation _40PPJ_'------ Prop. Line ,._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -.-----------_-----) <br /> Septic Tank (Specify Requirements► - .. ----- --------------------------------------- --- - -- ---------------- ---..----------- <br /> Disposal Field (Specify Requirements) __-------------------------------------------- --- -------- ------- ------------------------------- <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 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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------------------- /f1 <br /> --------------------------------------------- -- Owner <br /> Y - ----- -------------------------------------------------------- Title -----4004— r /7_'0; _. - L�-GAek--,_ <br /> B <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------ ----------------------- -.._-.--- ----. DATE ...4----_/.'L- ? ---------- <br /> BUILDING PERMIT ISSUED --------------------- - -----DATE <br /> ADDITIONALCOMMENTS ------ ------------------------------------ ---------•------------------------------ ----------- ---------------------_---.. <br /> --------------------- -------------------------------------------------- ----------------------- ------ ---------- -- ------- ----- -- ---------------------------------------------- <br /> --- <br /> -------------------------- --- -------- -- <br /> �------------- <br /> Final Inspection by: _ ---------------------------------------------------- ----- --------------Date ./a,_W.; <br /> ----------------------- <br /> SAN <br /> -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />