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"'FOR OFFICE USE: aAPPLICATION FOR SANITATION PERMIT cq} <br /> ... .................................................... Permit No. <br /> .................................. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued ............. <br /> Application is hereby mode 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. 544 and existing Rules and Regulations: <br /> JOB: ADDRESS/LOCATION ...::.:IQp! --.......`v"f........d Ute.. <br /> .. ..................................CENSUS TRACT ..............:...... <br /> :.... <br /> Owners Name �'��.`•:� 09 _....pd..C-.4� ... .........Phone <br /> f Address _3 :J - . __.._. •------------------------ ------------------City f_!_!y/kT Cf.`1-..................... --•---..........._........ <br /> I fir �.b _v_I�_...' `..SCT ! .-------•----- --------license #� .'. S�G.. Phone <br /> Contractor's Name ......-.!........ ... .. .. � <br /> Installation will serve: Residence Qg Apartment House Commercial OTroller Court 0 <br /> Motel ❑Other ----------------------------------------•--- ,y <br /> Number of Living units:..... 1'.__. Number of bedrooms ..J.......Garbage Grinder ............ Lot Size ...1.�y-/r 5�---•-------------- <br /> Water Supply: Public System and name ..............................................................................................................Private, <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ® Clay Loam ❑ Q <br /> Hardpan ❑ Adobe.0 Fill Material ............ If yes,type -_..___-_..___-•_.-_--____.. , Q <br /> (Plot pion, showing size of lot, location of sy st m inn relation o ell's b lding ettmvst'be pldtea�on revs side.} <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [.] Size....��.�X. ''.�C..9..�............... Liquid Depth ................ <br /> Capacity Type Prf.C�!sTa-Material..-C--- C... No. Compartments <br /> . ............. <br /> Distance to nearest: Well .......'.54...................Foundation ....Lo............ Prop Line a-'rR............. <br /> LEACHING LINE [ ] No. of Lines foo s !=T_ Length of each line.P"`-r4.r9''j'r-/Total Length i <br /> D` Box ..../..... Type Filter Material _f�....Depth Filter Material ---_3_X_1.......... ........... <br /> k Distance to nearest: Well .. 5: ........... Foundation .............. Property Line .�b.�............. <br /> i SEEPAGE PIT [ j�` Depth ..................... Diameter ................ Number ............................ Rock Filled Yes [INo (] <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 /> rDisposal Field (Specify Requirements) --•---•-•--•-------------------•-.---------------•-••--••--------•----•-----•••-•..........•-•-------•--•••------••••...........------ <br /> -----------------•-------------------------.._.. . ------....------•-------.....----••-----------------•-----••......---------•••----•._...•-•-------•-----••-•------.........._ --------••--- <br /> r <br /> l --------- <br /> -------------------------------,-------- (Dra-----w---e-xist-- ------ing---•---and--,r'e'- <br /> --re.q...uire.. ----a' <br /> --dition-- ------on ---s• •ide-•]----------------------------------------------------------- <br /> -��-•••-� �.:� d drev <br /> 1 hereby certify that I have prepared this application and that the work will"'b ishe;'in-accordance-with,�Sanmr oa4uin, <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 far which this permit is issued, I shall not employ any person in such manna# <br /> as to become subject to Workman's Compensation laws of California." x <br /> L <br /> f Signed .._. ` _ .. . .rJA. ......� arca . .......... .... Owner <br /> By ........... --------- --- . ........:......... . . ---- Title ........_... ....................................................... <br /> (If other wrier) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... _._.. --------------------------------- .................................... DATE .__....... . :�. ................... <br /> BUILDING PERMIT ISSUED ...._ ... <br /> ....... ..........................DATE --•-------------•.......................... <br /> I ADDITIONAL COMMENTS ....................................................I...._........----•-.... ........................................... <br /> ...:...._...._............. <br /> .... <br /> -............................................. . .........:...........•....................................................................................:............. --------------•-•_.... <br /> !� . <br /> { .......... ........................... ................................-•---•-•----............_......... .................................... --...... ........... <br /> .. <br /> Final Inspection by: :.........................................Date .......... ........................... <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.1-3 24 1.'68-Rev. SM 7/72 3 M <br />