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FOR,;OFFACE-:U-SE� .. <br /> � - PPLICATION FOR—SANITATION PERMITf- <br /> _ <br /> . ..... ....._....'......... <br /> Permit N <br /> o <br /> :.. <br /> (Complete in Triplicate( <br /> ..:.�: ........--- y <br /> T /j This Perm}Ex ices 1 Year From Date Issued Date Issued <br /> E................................__.:...._........_.:_ <br /> • .�- <br /> Application is here'b-V de to the San Joaquin Loeal Health District for a permit to construct and install the work herein <br /> f described...This application is made in comphonce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT18N .' ..... Q(! ..: .�/.. ............CENSUS TRACT .................,.._.. .. <br /> } Owner's Namei...._.._ 'Ct- __-. +�__ �!_ . .�. hone u --. _ . � .� <br /> Address .r' . . . . . .. . <br /> a �.A..__. .'1 �2� :- = .. City _./:.2���► <br /> Contractor's Nome ..tf _ ?.: ?:�'+r.��f--.. ._..r�l�/- :.. ..:.license # .1 . " _.. Phone <br /> Installation will serve: Residence-C] Apartment House,E Commercial $Trailer Court <br /> W <br /> Number of livingunits------------- Number of,bedrooms -__:..--_.:_Garbo e.Grinder ___-_______. Lot <br /> Motel Other-_:----- <br /> .. ...,,. <br /> �. 9 Size -------------=---•--• J <br /> Water Supply: Public System and <br /> name =-.:..:...... ----•---------------•---------------­-----------.. Private.® . .. <br /> 1 � <br /> Character of soil to a depth of 3 feet: Sand ❑ Cl <br /> 'Silt[Q ay- ❑ Peat❑ Sandy Loam Clay Loam - <br /> , u <br /> Hardpan-E] Adobe.:❑, Fill.Material _._.__._.... If yes,type ---------------------------- <br /> f w <br /> (Plot plan, showing size of lot, location of.•_system in relation to.wells, buildings, etc. must.be placed on_reverse sidd.) <br /> NEW INSTALLATION: (No septic tank or:seepage pit-permitted-if public sewer is available within 200 feet,[ ! (1 F <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ................... ......... <br /> ;`Size....... .:.. .:....... Liquid Depth _....--_-------._... <br /> _---A <br /> Ca aci <br /> p ty - TypeA__ Material_._ fcr_-. No. Compartments ., ........... <br /> I Distance to nearest: Well'--.--- .............Foundation ..-------_........... Prop. Line ...................t.f <br /> LEACHING LINE [ j No. of Lines ....... ............. Length of each line.-._._70............... dotal Length f�.......___..._..... . <br /> 'D' Box Type Filter Material' ' . ":Depth Filter Material _ ; <br /> -_.. <br /> Distance to nearest: Well -------------...........: Foundat.ion ::.__.._-_-------_----_ Property Line .................... <br /> SEEPAGE PIT [ j Depth - <br /> Diameter .......e........ .Number •.......................:.... Rock Filled Yes ❑ No <br /> Water Table Depth ......:....Rock Size A- <br /> Distance to nearest: Well ...................................... Foundation ......... Prop. Line --_.____------.---_L_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit 7# !!.... L..�. r..C._.........: Date .. .'"Z Z—.f _....._.I <br /> r / <br /> Septic Tank (Specify Requirements) --------------- ...... ... --• ----.._................ <br /> Disposal Field (Specify Requirements) ----------- _---------• ...... --•-•--------- ------------------------------------------------ ------- ......... _ <br /> ............................•........................ ............................................................. ......................._........... ...........----------• --- ......................... <br /> -------------------------------------•----------------------------------------------------------......._-----------------------------------------------------. ....... --------------------•------ <br /> j' i {Draw existing and required addition on reverse side) <br /> 1 I hereby certify that L 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, dome 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, 1 shall not employ any person In such manner ^. <br /> as to become subject to Workman's C", pensation laws 'of'Cal ifornia. <br /> -Signed -- ... c .... .. Owner <br /> ,. By .. `l' <br /> ------- ...:.......:...:: Title ..........:__............. ......._..._..._.......------------------. <br /> �ownerl ¢ . . <br /> t7 FOR DEPARTMENT USE ONLY <br /> --- `--•-------------- -- . <br /> APPLICATION ACCEPTED BY ......... DA DATE .... ....'".�`..7`�.............. <br /> .... ...�_. .. <br /> BUILDING PERMIT ISSUED ------ _ ............. _DATE........,......:. .- - <br /> ADDITIONAL COMMENTS ...... ............. . . _ ...... <br /> -•-------------------------------•-••-- .. _. _.. .. <br /> . .. ... ._.. :_ <br /> ' ... j <br /> Final Inspection ..... ...r--------------•----------•-------Date ...I.r�4 . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ _ w v• . .,. <br /> ? E_ H_13 24 i.-A.4 Qa._ 5M 7172 3 M <br />