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FOR OFF*CE.U5E: t • 4 <br /> _ <br /> - <br /> APPLICATION FOUR SANITATION PERMIT <br /> ------------ -- - Permit No. <br /> (Complete in Triplicate) -- <br /> ---------------------------------------------------------- <br /> ___________________________ This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._.-_��_ -7l t_—----- ------------------------------CENSUS TRACT ------ <br /> Owner's <br /> ----Owner's Name .Q1L--------------- - <br /> -------------------------•-------- ---------------..__Phone ------------------------------------ <br /> ------ <br /> Address ----------------------14.13 �-= Cit <br /> Contractor's Name4__._ _ _ - License # +55 D Phone_-?Z.l/ra y <br /> Installation will serve: Residence partment House Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--/ ------ Number of bedroomsg <br /> �____Gdrba e Grinder -____._____ Lot Size <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private EAP --`� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- �. <br /> (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepag it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ Size---- -------- Liquid Depth ............. <br /> Ca acity ---/�G_ ><"-__ Type ----- /Material---------------------- No. Compartments - <br /> ---- <br /> --stance to nearest: Well -----�_ __ ��J f 7 <br /> -- -----------Foundation -- ------------------- Prop. Line ---�--------------- <br /> LEACHING LINE No. of Lines -----ate_______________ Length of each line......jq_�-__�_...___._ Total Length ---�__-V-0__�_-_.-- <br /> 'D' Box __ ______ 7 e Filter Material ! // (� <br /> YP / - - Depth Filter Material ____+ __-__________________________ \ <br /> Distance to nearest: Well '-:--.------------------ Foundation ------------------------ Property Line ____________-_____._____ <br /> SEEPAGE PIT [ ] Depth _______ Diameter -------------- Number ---------------------------- Rock Filled Yes (] No <br /> Water Table Depth ------�-j-- - Rock Size - _ <br /> Distance to nearest: Well ________________;_______________________Foundation ___ --------------- Prop. Line.____.______.__________ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-__--__.--______________ ----------------- Date _____- ______________ ) , <br /> SepticTank (Specify Requirements) ----- ------------------------------------------------ ---------------•------------------------------••---------------------------- <br /> DisposalField (Specify Requirements) ---------• -- -------------------------------------------------=----�----------------------------------------------- --------------- <br /> - -: ------ . -i ----------------------------------•------------------------- <br /> ---------------------------------__------___----------------------------------------- _-______________-______--__---_-_--.-------_--__________ __ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and4hatithe 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 licen- <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 subject to orkma Cor nsation aws of California." <br /> Signed K�= - 1 -- �` --- --------------- ------- Owner <br /> BY ----- - --- -----------------"q---------------- "fir------- " ------------ ------------------- Title ------ ---------- <br /> [If other than owner) <br /> a <;FOR DEPARTMENT USE ONLY <br /> T <br /> APPLICATION ACCEPTED BY .... --t&___0------------------------------------ ------------------- ---------------- DATE --5-3 i'=-7-2 ------ <br /> BUILDINGPERMIT ISSUED ------ -------------------------- -------------------------------------------------------------------- --DATE ---- -------------------------------------- <br /> ADDITIONALCOMMENTS .-------- ----------------------------------------- -------------------------------------------------------------------- --------- <br /> ------------------------ ------- ------------------------- - -------- ------------------------ -------- ------------------------ ----------------------------- - <br /> -------------- -------------------- -- --- - - - ------- ------- - <br /> Final Insp ---------------Date _... <br /> SAN JOAQUIN LOCAL H,`�NLTH DISTRICT ,fig <br /> ' <br /> E. H. 9 1-'6$ Rev. 5M <br />