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FOR OFFICE FUSE: T 't <br /> APPLICATION FOR SANITATION 1'ERM1T"" � <br /> -- ----------------- <br /> a Permit <br /> - Triplicate) No. <br /> (Complete Trip icate -� - <br /> ---------------= ----------- ------ .: 7 <br /> Date Issued <br /> I� i This Permit Expires 1 Year From Date Issued <br /> i r <br /> Applfication is hereby made to the San Joaquin Local Health District for a per 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 /> ' rCeJ___v__._CENSUS TRACT --------------- <br /> JOB <br /> -------------JOB ADDRESS/LOCATION�� ------� --- L-`� _ /�a <br /> �. <br /> p Name ` � x"s'si <br /> caner s -- - �- - - -- - - - � - --- - ---•--- <br /> r, <br /> Address `� ----- ---------- ----�=--'CitY -- ---------- <br /> ------------- ........ <br /> s <br /> , �- - . <br /> l $ r+ .- _-- i License # PE�one _- -- <br /> Contractor's Nam '---- _.f = ., <br /> �a <br /> f . _ <br /> iI <br /> Installation will serve: Residence*Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel❑ Other ---- ----------- = <br /> ----•--- - -----------•--- �:�, . : _x .� <br /> Number of living units:-__ ------- Number of bedrooms _;_____Garbage Grinder _:_: Lot Size _: <br /> Water Supply: Public System and n'aine _____________________ _ __ ____:___.Private <br /> ____ _ ________________.______._ !i______.____t y <br /> PpY� Y - ---- - - - - <br /> Cha atter of soil•fo a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ I Peat❑ Sandy Loam ❑ fClay Loam ❑ <br /> X ',Hardpan ❑ Adobe Fill Material ---------- -If yes,type ---- - ---------r-------- W <br /> X. <br /> [Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.[ Q <br /> r,r , <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public ew,'r available within 200�if+eet,[ Q <br /> TANK' <br /> Size--------`------------------ Liquid JDepth -----------•------ -- <br /> PACKAGE TREATMENT [ ]" SEPTdC I ] <br /> I No. Com artments _ -----------­------- <br /> Capacity <br /> =__._-- - <br /> " . . <br /> Capacit _ Type -------------------- Material---- <br /> -------r- -. p - --------• <br /> � Foundation�---�---�------------- Prop. Line -_.`�"'_'-------- - <br /> ' � Distance to nearest-. Well ------------------------------------ � +: <br /> P <br /> LEACHINGUNE� [ ] No. of Lines __---____t._ ___ Length of each line ___-_ "-�'� .'"� Total Length ;-:___-_-..____-•-___.._-__ <br /> ' h 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•-------------•------ -- <br /> »-_ P_ro er•. Line_-_ ---------------------­ <br /> Distance <br /> to nearest WeIL---------- ---------------F.oundation_------------------------- P tY� <br /> - Rock FiIled s ❑ No �❑ <br /> SEEPAGE PIT ,,[I] Depth ---------`---------- 'Diameter.__ :T__ Numbers -_ - - ��- - Yz <br /> Water Table ;Depth ---------------------------Rock Size --------------------------------- <br /> tip, <br /> ------------------------ ----- <br /> 1 11I --------- -------Foundation ------ Prop. Line <br /> � Distance to nearest: Well __-_-_-_______________ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------------- } <br /> ! Septic Tank (Specify Requirements)1,--------=-------------------------------------------- ----------------------------------------------- - .-- <br /> G - --_----f --- ---i ` .1 .� ---- � --�--— - <br /> Dis sal Field,-(Specify Requirements} <br /> t -------------------------------- <br /> - - f I - <br /> -- -- -------------'---------------------------------------------- ------------ = <br /> 3 (Draw existing and required addition on reverse side) <br /> I hereby certify that II have prepared this application and that the work will be done in accorifance with San Joaquin <br /> ' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- <br /> sed agent"s signature certifies-the followin <br /> "I certify that in'the performance of the work for which this permit is issued, I shall not employs any person in such manner <br /> as tobecome subject to Workman's Compensation laws of California." <br /> .—Signe ---------- Owner <br /> ij Title -------- ------- -------------------- <br /> - --------------- - - <br /> ` (If other than owner) <br /> _ # FOR DEPARTMENT USE ONLY <br /> DATE __..�� --71----------- <br /> ° APPLICATION ACCEPTED BY - _ -------�'---`---------------------------------- ---- - <br /> BUILDING PERMIT.:ISSUED -- ------ -- -------------- --------- ---d, -------------------- DATEzgol <br /> ADDITIONAL COMMENTS -lam <br /> ----------- <br /> 44 <br /> -------------- <br /> ------ ----------------------- a ------- -- ----------------------------- <br /> ------------ -- <br /> ---------- ------- <br /> Final4�nspection by: ----- ------- --- --------------------------------------------- --- ---------------------------Date <br /> s" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />