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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT <br /> Permit No. X.5 3�. <br /> .................................................... (Complete hi Triplicate! <br /> .............................................I........... Date Issued <br /> ......................................................... This Permit Expires I Year From Daft Issued i <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 rdinance No. 549 and existing Rules and Regulations, <br /> SOB ADDRESS/tOCATIoNc'�.l.c� .. .. .....................................CENSUS TRACT .......................... <br /> Owner's Name .... ,• ................................. ................. ...Phone �'C�..' a�P ;....:.. <br /> Address '- .............................................City • _ 4r :9�® `7... <br /> Contractor's Name .. - ..................License#CRS.zn f.2l�..�.- phone <br /> Installation will serves Residence 6 Apartment House 9 Commercial❑Troller Court ❑ <br /> Motel❑Other-•......:........................•-•--...... <br /> Number of living units:...J----- Number of bedrooms Garbage Grinder, . ... Lot ze �'� � <br /> - ----- - ,.W.. .... .. ----�c�:................Private ❑.....--- <br /> i Water Supply: Public System and name =' <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Pea ❑ Sandy Loam ❑ Clay loam <br /> Hardpan❑ Adobe)§ Fill Material ............If yes,type ............... ............ <br /> $Piot pian, showing size of lot,-I&Wlon--cf-system--in-relation-ta-wells; buildings, etc. must be placed an reverse side.} <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ SEPTIC TANK,( ]^� f Size................................................ Liquid Depth ...................... <br /> Capacity l .. "...'... Type ............... M feriai__............._...- 'No. Compartments ----................. <br /> • Distance to nearest: Well ........................:. ..Foundat;an ...................... Prop. Line .................... <br /> .... <br /> LEACHING LINE [ D No. of Lines ......1............... Length of each..lino!.11V................. Total Length ............................. <br /> �• 'D' Box ------- Type Filter Material ....................Depth filter Material ............................................ <br /> Distance to nearest: Weil-...'.................... foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ D Depth ................ . Diameter Number..:......-----............... Rock Filled Yes ❑ No ❑ <br /> Water Table Depth -............I....................................Rock Size ................................ <br /> Distance to nearests Well`-:__-• ........ .............. ..Foundation ......... Prop. Line <br /> ........._---------- <br /> REPAIR/ADDITION(Prey. Sanitation Permit f ....7:41.7-:CT....... - . -Date ............... <br /> —2• a-} - <br /> irements ----z t . . .. .................... ....................................: ............................... <br /> Septic Tank (Specify Retia } <br /> Disposal Field (Specify Requirements} ...:. <br /> ­a— <br /> Disposal .................................... ....... <br /> ♦$ <br /> (D w existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be dons In accordance wlth Sae Joaquin <br /> County Ordinances, State Laws, nd Rules and Regulations of the San Joaquin Local Health District. HMGM*_oe Owner <br /> r or lkertt <br /> sed agents signature certifies the following: <br /> "I certify than In the perFormance of the'work for which this permit is issued, I shall not employ any person In such manner <br /> as to beco Ott t rkman's Compens [on laws of lifornla." <br /> Signed ...- .... . ... .... .. . . ~ . .:. ........ ----•................... ........ <br /> � � . ®ws►er <br /> .. ...... ....-•- . - ...." . `.. .'xitie..... � .... <br /> _ 1 <br /> If other anweer} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. - DATE -. .:.".. ...:. :-: <br /> BUILDING PERMIT ISSUED _.........:....... <br /> DATE .................................. <br /> ADDITIONALCOMMENTS ...................................................-. ..._..Y. ... ........:-••-•--.....................-...........:.....---...........-------- <br /> i ..:.. ------•-- <br /> .. <br /> T .-•---•......................... ............................ - .....-.-,....... <br /> : •, <br /> ...................................... <br /> ................... _ .Date .-' <br /> Final Inspection by: f 'i' ;� ..............•-•-... ..................--.......- ; <br /> Mi 13 2!i 1..68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT /?Di 3M <br />