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� � l <br /> FOR OFFICE OSE.- 4 <br /> APPLICATION FOR SANITATION PERMIT...... Permit No. -7 .:-./�7. <br /> (Complete In Triplicate) <br /> .................................................. <br /> ...... This Permit Expires i Year From Data Issued Date Issued -..1............. <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 ,...... _. .e ... _-r.__. � ,t •- -.•..)1.14!1 NSUS 'TRACY .......................... <br /> Owner's Name ..... ....Phone <br /> (� r <br /> t _ _ <br /> t <br /> Address ._. .. . _©_. <br /> •- - ..�. . _�---�'6f... ..................... city ......................---......-•--••-----•------- <br /> Contractor's Name License # Jx-°1 7... Phone . .(... <br /> . ,... . <br /> Installation will serve: Residence XApartment House 0 Commercial ❑Trailer Court <br /> Motel ❑Other ............................................ <br /> Number of living units;--- Number of bed ooms __�`�......Garbage Grinder.--�. Lot Size .7-__�-�'�'�-............... <br /> Water Supply: Public System and name ......./=. �dlme................................................Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam O Clay Loam D <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 /> PACKAGE TREATMENT [ J SEPTIC TANK Size.1� ... ..... Liquid Depth .._117................ <br /> Capacity/-.. d.C7.4*4 Type d,,?1-40�Materiai.l� No. Compartments ..,1-.......... <br /> .._.. . .1 <br /> Distance to nearest: Well <br /> . ------•-------•---- Foundationfl----------•••• Prop. Line . ............. j► <br /> LEACHING LINE~ ( No. of Lines ........3------------- Length of each line----- Total Length c -VV..°..........10 <br /> 'D' Box ---joo�. Type Filter Material Aeot Filter Material <br /> ._ . .r..--------------------------- <br /> Distance to nearest: Well .. Foundation .. .�_..__..__. Property Line 1''n <br /> SEEPAGE PIT ( 1 ' Depth .................... Diameter ................ Number ------------ --------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth .......Rock Size <br /> Distance to nearest: Well ........................................Foundation ..... Prop. Line G <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _........................................... Date ..................................) <br /> SepticTank (Specify Requirements) -------------------------------------------------..........................................................................................P <br /> DisposalField (Specify Requirements) ---------•----•----•--•• ---••.................................•--._...--------._.......••------------••------..._.._.._....---•-• <br /> -----------•--.._.............------ ..............................................................-•..........----------------------------------------------------------------------------- ------------- <br /> ----------------------------­ <br /> --•----•-------------------------•------- ..-_ -------------------------------------------------------- ...........-.........................................:........_—.:_..._ ....... <br /> (Draw existing and required addition 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. Horne 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 persons in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ..... ................I...........I...... Owner <br /> By .._..._. ---- <br /> . Title ....<. _ <br /> ............................... <br /> (if other than ,w PiV7 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... ........` .........-..._ .................. DATE -.. .�/.. -7 y <br /> BUILDINGPERMIT ISSUED ......---•-----•••••--••...........................•-------------•--------•--------...._...-•----.........DATE .......................................... <br /> ADDITIONALCOMMENTS . ------. -- •--- •-•--•......--,----••--------------------•--......_._..._.._....................................... <br /> ..........................-..---- -- ..... ---•-................. •-••--•---...._...--•-••----....._....-----.....--------........_...........•. ....... <br /> ............... .. .. ..................................................... ....... <br /> Final Inspection b ........--.Date .._.3._._. ---.. <br /> P y .... ----•---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.3-3 24 1-'68 Rev. 5M 7/72 3 M <br />