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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Z <br /> .................................. Permit No. 7....:.7.7 <br /> {Complete in Triplicate? <br /> ........................................ <br /> • <br /> This Permit Expires 1 Year From Date Issued Date Issued ..�.�.�..:. f <br />........................................................ <br /> Applicotian 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 <br /> egulations:JOB ADDRESS/LOCATION ,.. 5_ . CENSUS TRACT :.............::.......... <br /> Owner's Name � ��...._.� !_. ld:�!....... /-.. .:. Ph ............................. <br /> Address �_ 'L Tr -----.._.._._......... City ,.47�.r. Lr,�` ..3.�,,....... <br /> Contractor',s Name..... ..r/�... eli�r s.-.-.- .................._.License # gRA6_5 ._Phone,�:.r.����. <br /> Installation will serve: ResidenceApartment House❑ Commercial [:]Trailer Court <br /> : g Motel ❑Other ............................................ G I <br /> Number of living units------- _... Number of bedrooms _,-a...Garba'ge Grinder .._ ........ Lot Size ..__.�..........:....................... <br /> Water Supply: Public System and name .............. .......................................: ......................r................. <br /> .. .Private <br /> Character of soil to a depth of 3 feet- Sand ❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpa Adobe '❑ Fill Material __--..--___ If yes,typ <br /> (Plot plan, showing size of lot, location,of system in relation to wells, buildings, etc. must be placed on reverse $W_4Q"A <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> k PACKAGE TREATMENT [ ] SEPTIC TANK Size................................................ Liquid Depth ...UZ............... <br /> Capacity --- Type,/ aff`G � Material-----•................ No. Compartments ------................ <br /> Distance to nearest: Well ....1._ ...-•----••••••••••••Foundation fit---------------- Prop. Line -------.---- <br /> , E. ...f.. ; ._� <br /> a! LeLEACHINGLength of each line.. ........--- <br /> De th Filter Material .......... <br /> -...................... <br /> 'D' Box .. --------Type,.-Filter Material t� ,9_ <br /> Distance to n arest•'Wel l ... ~ ......' . Foundation ...( ....... Property Line ._,� _1........_ <br /> SEEPAGE PIT [ ) Depth J' __._: •Diameter .. .... Number .... _________________ Rock Filled Yes No <br /> ,F <br /> Water Table Depth :. ..........`.:f...................Rock Size ................................. <br /> Distance tot-Well --------------- '..4.•_.._....._.....Foundation .................... Prop. Lime .......... <br /> REPAIR/ADDITION(Prey. Sanitation" erm�t`4 ................. Date ..................................) <br /> Septic Tank {Specify Requirements) .............� r; ----------------------•--------.-.-......----------------------------- <br /> DisposalField (Specify Requirements) ..:............................. ------ ............... --------------------•- ...................................................... <br /> + ------------------------•----- ...........................------------.-._..._...........---------------------------------------------------------- -------­--- ---------------- ................... <br /> i1 _ ...................... <br /> T -` <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 Iicen- <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 <br /> as to become subjec orkm `s Compensation laws�of California." y.P <br /> Signed ..._ ....ww ::.. : Owner <br /> •------._ Jitle ...................................................:.................... <br /> (if other than owner) , <br /> SFO EPARTMENT USE ONLY � <br /> q <br /> ---APPLICATION-ACCEPTED 8Y ___ ----- ------------ .... ----------•--~ <br /> BUILDING PERMIT-ISSUED _-----...... .-•-•-••.. <br /> 1 <br /> ADDITIONAL COMMENTS ........... ...................... ..................... <br /> '.:�--------------- <br /> .............................. - ._. - T..:.: -:.LL..:..:. .................................... "-�---...----•-•------� <br /> i <br /> .....--•.. .............. .................... ...:. • -- ------•--.._...---------•-----........... :..... �3 .._..... .._ <br /> Final InsAection by: L',:. Date _ .. ..f. , <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> i <br /> 9 u'13-_.24 1.,,&a ¢�_ slut 7/_72 3 X <br />