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FOP,OFFICE USE: . <br /> APPLICATION FOR SANITATION PERMIT // <br /> {Complete in Triplicate} Permit No. .. .............. <br /> ................................{...._._.__....--..... This PernriltExpire* 1 Year from Date Issued <br /> Dane 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 /> __ i T 6�ro�[ f' .......................... <br /> - - .CENSUS TRACT <br /> JOB ADRRI=SS/LOCATION ....y.`L..�_y.... ....._.._...._� 9.�.....:.:...,.............. . .... .... ......... <br /> s 763 .....- <br /> Owner's Name ....SY Ma dA:-----01...................................................................................Phone ...��' ........... 7 <br /> Address . .P. .. .fIX..----.3.-'. f .......9S3-Q y.............: ........................-"•- <br /> Contractor's Name .:./��'.t!5..�7...�.`.•..... ...................... . _-..-.License # ..... Phone ...`7.�6.f�..9.....Q7_.. <br /> 6 <br /> Installation will serve: Residence❑Apartment House Commercial oraller Court 0 � <br /> Motel ❑Other . ..................................... :. <br /> r - <br /> ........_Garbage Grinder ...... :.. Lot Size .......................................:.. <br /> Numberting unit_..__.__.___ Number of bedrooms �Garbe � .� <br /> Water.Supply.•�Public-S stem and name ... Private <br /> Character of-soil to a depth of 3 feet: Sand❑ -Silt❑ *--Clay.Qj`�PeatQ Sandy Loam 0 Cloy Loam E3 ' <br /> Y . — Hardpan ❑ Adobe ill 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: (Noeptic tank or seepage .pit ;permitted If public sewer is available-within 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC ] ' • Size--=-:..':..:.....I......... ............. Liquid Depth ..:.:.. ..:.............. <br /> Capacity - ,:,---------------- Type --------- .......... Material.--------------- -- Nb:Compartments <br /> Distance to nearest: Well .......Foundation .................... Pro Line <br /> Length of each line............:. -Total- .. l <br /> LEACHING LINE [ t No. of Lines --------------_------ 9 Length ............................ <br /> 'D' Box .--- :.._-- Type Filter Material ....................Depth Filter Material .........--- <br /> Distance to nearest: Well ------------------------- Foundation . Property Line .....•..•.• <br /> ............ <br /> SEEPAGE PIT Depth ... Diameter ----•--.--_--_-- `Number ............................ Rock Filled Yes ❑ No 0 <br /> Water Table Depth --------------------------------------..........Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _...----..............................._.... Date ............. .................... <br />` Septic Tank (Specify Requirements) ................... <br /> A.................. «....t- - --................ <br /> 7�4i I� v►G h u Z.S / $ <br /> pisposal Field {Specify Requirementst .-- .........Tl........... ................._........p-......... 5�_.......X_....... .. <br /> t - <br /> ----------------------------------------------------------------------------------------------------------------------..........-------.....:......................................................... <br /> (Draw existing and required addition on reverse sidel <br /> 1 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: • - °' .X <br /> "I certify that in the performance of the work for which this permit is issued, l shall not employ any person In such manner <br /> as to become ubje to Wor man' Cam ensation laws of California." <br /> Owner <br /> r <br /> Signed --------���­ -- -------------=�`--- --- ---------------------------------------_- ..� <br /> BY -------------- ------ ----------------- <br /> - Ti#Ie <br /> (If other than owner) <br />{ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ --a- - --- -------•--- ----- ................ <br /> DATE <br /> BUILDING PERMIT ISSUED ---------------------- ------------ -- :. ---- . ...7.. <br /> ...----•-•-----------------•--..._..-----------....--------•.-..---DATE .�..._.....�..._.._..:.. ..--•-- --._..--- <br /> ADDITIONALCOMMENTS .....................•----------. ----•-- ------ ................_..._.--.......---•-----...--•------..---------------••-- ......I.................... <br /> ------------------ --------------------------------- -----------------------------------.._.....----------------- -----------------------................................_. ---------------........ <br /> . <br /> final Inspection by: ': ---...--•--"---...--".................... ..... I ate ...... f... ..... .. <br /> ----- <br /> EH <br /> 13 2 ' v• 5mSAN JOAQUIN LOCAL HEALTH. DISTRICT 8/711 3M <br /> x <br /> .4 <br /> F - <br />