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FOR OFFICE USE: <br /> APPLICAYION FOR SANITATION PERMIT ` <br /> f ' fCompleto In Triplicate) Permit No. �--_-+ <br /> .................... <br /> -..........I ... Date issued ..�" <br /> .........-•---•........:.....................:.......... This Permlt Expires 1 Year from Date Issued <br /> Application is hereby made to the San Joaquin local Health Distrid,,,for a permit to construct and install the work herein <br /> k described. This application is made in compliance-with County Ordinance No. 549 and existing Rules and Regulations: <br /> I <br /> I <br /> F" JOB ADDRE5S/LOCATIO D. . ............... c ..CENSUS TRACT .............- <br /> Owner's Name ----- ,�� � �..-•---�[ !p.............. ................Phone <br /> - ..r <br /> ... <br /> Address /'. ` �' �i�G�il ............. City ...._.fl �? {�7t� --------- •---- •---- <br /> Contractor's Nome ......................................License # --••.................... Phone ............................... <br /> Installation will serve: i Residence©Apartment Ho se C) Commercial❑Trailer Court 0 <br /> Motel []Other- fi --=------------- <br /> J � <br /> Number of living u. <br /> "its Number of bedrooms _ Garbage Grinder ............ Lot Size . ... ..... ................ . <br /> Water Supply: Public System and name .........4..,�1 ._.._.k} �'.._....---.-• ......................Private <br /> I� fi <br /> Character of soil to a depth of 3 feet: Sand.❑ Silt.Q" Clay ❑ Peat❑ Sandy Loam; ❑. Clay Loam ❑ <br /> � Hardpan p Adobe❑ I'itl Material ............ If yes,type............... ...........• <br /> 4� <br /> Mot plan As howing size 'of lot, location of system in relation to wells, buildings, etc. must be placed on reverse slde.) <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 /> Copacity ---- Type ----------'........... Material....................... No. Compartments <br /> �` Foundation <br /> Distance. to nes est:,Well ........::... ..... Prop. Line <br /> LEACHING LINE [ } No. of Lines ........................ length of each line............................ Total Length ............................ <br /> f?' Box Type filter Material � .....-Depth Filter Material <br /> ............................................ <br /> Distance to nearest: Well .................4 :....... Foundation k..... ---I-----..... .. Property Line ........................ <br /> SEEPAGE PIT [ ! Depth -------------------- Diometerl',......�......... Number :.-- _.............. Rock filled Yes ❑ No <br /> Water Table Depth ------'---------_-_-• ..........::.:.....Rock Size . .....-•---••--- <br /> Distance to nearest: Well ' ..:�.:.:Foundatiori .._ Prop. Line <br /> k <br /> REPAIR/AQDlTION{Frau. Sanitation Permit# �..... <br /> ...............•---------•-----__-- Date -... V�0; <br /> = -.. --:- - . <br /> Septic Tank (Specify Requirements).----- rcP�..: Iir.... /` ��. ........ <br /> , ... <br /> Disposal Field (Specify'!Requirements) ..... ....._.ca c .�'• _..... �'�.-, � -------------------.........-.............. <br /> . <br /> ----•-•-------------------------•---......IM.....--•------ --- .. <br /> ---------------------------------- ------------------------------------------ •-------•- -------...._..............-•--- <br /> (Draw existing and required addition on reverse side) <br /> j 1 hereby certify that I havprepare <br /> �e. d 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 Heallh.District. Herne owner of <br /> licen-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 beta subject tq Workman's Cps9pensation la of California." <br /> Signed - _ - Owner <br /> BY - 'M •----------- ............. Title _. ........ ..........-----....------.............--- .......... <br /> (if other than owner) <br /> —FOR D N ONLY—hA <br /> M -- --- <br /> - <br /> APPLICATION- A-C--CEPTEb B� X <br /> DATE -------------- <br /> -------= <br /> DIPERMIT :DACE _ M <br /> ADDITIONAL OMMNTSp--- ..... - :.: = ----- <br /> - ---`---- - - _ <br /> -------------- --- ------ ---- ----- <br /> -------------------------------- <br /> lr .. �.......... <br /> ------ -------------- ------------_--------- ............Date ~- ..... --- - - ..........`final Inspection by.-; <br /> Eli 13 2h 1-68 Rev; 5M, SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7}t 3M <br /> II`` <br />