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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> .........................•------.............. 77- <br /> "' ! Permit No. <br /> ..........I.............................................. <br /> lComplete'In Triplicate) .......... .......... <br /> 7 <br /> ............. ......... This Permit Expires VYlriar From Date Issued Date Issued -lY <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 -��/©0 �?-. ..._ J..V' .- CENSUS TRACT <br /> Owner's Name / .r5'/..c�cr� _ 20 ,5................. .....Phony <br /> Address Ci <br /> Contractor's Name ---- _6e7,-. ..._yfV4,-at :..................license # 46S'.-WeR.3__ Phone <br /> Installation will serve: Residence ❑Apartment House Commercial❑Traller 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 too depth of 3 feet: Sand r] Silt❑ Clay. ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ <br /> Hardpan ❑ Adobe Flit Moterlal ..__._...... 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: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,] 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size................................................ Liquid Depth .... ................. Z <br /> Capacity -----------•---•---- Type --.._..---•-------_. Material...................... No. Compartments ...................... <br /> Distance to nearest: Well ._.................................Foundation ...................... Prop. Line -.--------------..---" <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line..........................._ Total Length <br /> 'D' Box .._... ..... Type Filter Material ....................Depth Filter Material ....... .................................... <br /> Distance to nearest: Well ------------------------ Foundation Property Line ........................ A <br /> SEEPAGE PIT [ j Depth ---------- Diameter ---------------- Number -.-- ..-------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------- -----•--------- ......Rock Size .-•-------...... ............... <br /> Distance to nearest: Well ----- ........Foundation .................... Prop. Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------.__._.... Date ---------------.__................) <br /> SepticTank (Specify Requirements) ----------- ----------------------------------------------------•---....:..----------------....---................................I -_....... <br /> Disposal Field (Specify Requirements) .7w- ,. .al'a...../.....-..._- :5 7(__� _�... . 5. --------zrk.�t1.fEfir............... <br /> \ j�4,%-Jc/ ...... xt. . y.....,. ... .� r —---------------------------------- . <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 �r <br /> as to becornw1mblect to Workman's Compensation laws of California." <br /> Signed •--. - <br /> - - 4Gt� -.r3s---- ----------•------- ------ Owner <br /> BY =-`-C -------C ----•-•--- Title, ' �G -c. .=--------------------------••---••• <br /> (if other than ownerl <br /> FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY -------------------- ...... ............... DATE ..I� rl- ----- <br /> BUILDING PERMIT ISSUED ------------ - - --- -------------------DATE ...-------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------ ------------...----------•---------•-•----------------------------.....---------------------........ <br /> ---------- ------ ................................... ------------------- ----------------------------------. <br /> ..........------------•-•--------------------------------------------------------------------------- -----•-------•----------......_............. --- ........ ...... ------ <br /> -- --•--------'-- -- . <br /> Final Inspection by: <br /> .. . .... .. .. . Date <br /> ..-------- ...------•-••- ' ..... -. <br /> ---------------------•------------------ -------..-------- --- .�-2 z. _... <br /> EN 13 24 1--68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />