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FOR PFFICE USE: t <br /> APPLICATION FOR SANITATION PERMIT <br /> l ICom letein Triplicate) Permit No. Sy-:��. � <br /> ............ ................ " ........... This Permit Expires 'I 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 comp1i with C my Ordinance No. 549 and existing Rules ant! Regulations. <br /> - <br /> p � + <br /> JOB ADDRESS/LOCATION .�.�b� -- ��(rJ- ---Apl�v._ //1/GfiJe<.............CENSUS TRACT ._...._........_-.. .._:._ <br /> Owner's Name v-lwr�.............. .... Phone .., /.,�t <br /> - / . <br /> Address ....--... - � /1C _:.--"--- -City�CP'"" / ------• .......................................... <br /> r: <br /> Contractor's Nama------: d -.� .. -w 'license # .. Phone ,f�1�',f <br /> E ';Installation will serve: Residenc Apartment House❑ Commercial ❑Trailer Court 0 � <br /> Motel F1 Other -_...... ................... <br /> Number of living units:.,.., - Number of, bedrooms 1 -Garbage Grinder. ............ Lot Size --- � .... .. r <br /> Water Supply: Public System and name ---- -------------- ---•-----• ---- ---.............:= ...... -------- --- --------- ----------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam E-] toarry� <br /> Hardpan ❑ Adobe ❑ Fill Material -------- --- 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> �r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK { ] Size....................... Liquid Depth -...--------....__._---- <br /> Capacity .: . .._.. . .."-•_ Type -.-_------_------_ Material........... ........... No. Compartments ------_-_- _.......... <br /> Distance to nearest: Well . . .:_:_- _...._Foundation ................ Prop. Line _.......... <br /> LEACHING LINE [ ] No. of Lines _: Lerigth of each .'_.s...-.......... Tota! Length <br /> Box <br /> Per Material ...-----------------Dept �Filter Material ...................... •------ <br /> Distance to nearest.- ----------------- Foundation ...... ........ Property Line .......... <br /> SEEPAGE PIT [ ] 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 ` <br /> ------------ ----•-- ----- Date ---•------------------•=------- <br /> Septic Tank (Specify Requirements) .. .- �.. .. .......... .-r.�_... .......... <br /> ... - -. . <br /> .` <br /> Disposal Field (Specify Requirements) D­ <br /> ....: . <br /> ---•-•---•-- ..... ........ ... ------ <br /> _-". ...............".. .."..... . ._. . a".'.--------- ._..._...---• <br /> (Draw xi ting and required ad on 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. Nome owner or Iicew <br /> sed agents signature certifies the following: <br /> "I>certify that in the perf ante of theark f which this permit is issued, I shall not employ any person in such manner <br /> as 'to becom subject t rkman's pensa i laws of California." <br /> Signed .:.. . �. .. .-".fir <br /> Byt. . .._.. --•-- -- - - •----------..} .—Title .:........ .... .. .....--- ..- <br /> er than o er) f <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ., DATE --X '_-_-_ <br /> BUILDING PERMIT ISSUED ._.__..._.-".... . ........................ - .......DATE _...................................... <br /> ..._. <br /> ADDITIONALCOMMENTS ---------------- 4............................. ------- .......... ...................A................................. ••---- <br /> .-----•--- -- ..........•........... -------------- -----------"---- ................................ ............................ .................... <br /> 1 <br /> Final Inspection by: .... .......... Date ..._.__ T . <br /> SAN .JOAQUIN LOCAL .HEALTH DISTRICT <br /> a <br />�. •_r u 13 241_'AA 0— A,kA 71723 M <br />