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—FOR OFFICE USE: <br /> ,. � APPLICATION FOR SANITATION PERMIT 'f <br /> ,._ .12. . .....-. Permit No. ......... .3 <br /> (Complete In Triplicate) <br /> ..................... 30-7 <br /> ' -• -~ This Permit,Expires 1-Year.-From Date Issued Date Issued ...'` :........... <br /> ............................. ..... <br /> Application is hereby made to the.San Joaquin Local Health District for a per to construct and install the work herein <br /> 4 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC ION ..........."L YJ-, P.`..__ ................................................CENSUS TRACT .._..._........._..__-•--• <br /> IOwner's Name ..... �. .'{.r..� I--..... >------ •---•----••-•.....---••........................:..---...............Phone ................... <br /> { <br /> Address .........................Rk 4_..-.- '.. --- ............ Cfty .... eO................... <br /> •.__.... <br /> Contractor's Name ....'�-=Q •. --- -----------•----....._...---.Licer►se #' 1 j_.. Phone <br /> �t <br /> l Installation will serve: Residence partment House C] Commercial {]Trailer Court 0 <br /> Motel ❑ Other ----.....:�'---__......................... <br /> Number of living units ........... Number of bedrooms _ �......Gorrboge Grinder t���.. Lot Size . . ._•0 ................ <br /> Water Supply: Public System and.name .... ..... -- !._..----...................... ....................... ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ ;'Clay Peat+❑ Sandy Loam C) Clay Loom ❑ <br /> � f <br /> 4 Hardpan ❑ Adobe r Fill Material If yes, type ............................ <br /> Y {Plot plan, showing size of lot, location of system in �efation to wells, buiicirigs,etc.must 'be placed on reverse side.y <br /> ' NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) " <br /> *.PACKAGE TREATMENT [ ] ;SEPTIC TANK I ] Size............................................ ... Liquid Depth •........ ................ <br /> E � 1 . <br /> Capacity Type _._ Material ..__ No. Compartments <br /> Distance to nearest.• Well .Foundation p. ' <br /> ......_.. ------ -••---- Pro Line ................... <br /> LEACHING LINE [ ] No. of Lines ........................ Alength of each line.--......................... Total Length ..._....._. ................ <br /> r <br /> 'D' Box .------._._ Type Filter Material ....................Depth Filter Material ................-----_�_____----- -------- <br /> Distonce to nearest: Well ........................ Foundation Property line ........................ <br /> r <br /> SEEPAGE PIT [ } Deptli�...-:._-. =..: Diameter <br /> ..:::.::::.:..Number:.__:.::..::..::-_- -Rock-Filled Yes Q No Q <br /> • Water Tahle Depth .Rock Size <br /> Distance to nearest: Well ......... .............................Foundation .................... Prop. Line ...................... <br /> + REPAIR/ADDITION(Prev. Sanitation Permit "f.......................... Date ....................... ---_---- <br /> Septic <br /> _. -:Septic Tank {Specify Requirements) .........--------------j--�-- fi..............-• ---- -----------............................. -------- <br /> Disposal Field (Specify Requirements)}....3t ....... .......... ...... J�.1. ... 1. <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 rind 4tbgula#ions of the Son Joaquin Local Health District. Home owner or licen. <br /> sed agents signature certifies the following: r �� <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 Workman's Compenatlon laws-of California." <br /> Signed <br /> -- - ._.,-Owner <br /> E ; <br /> c � ------------- Title <br /> (if other ha owner) <br /> { <br /> FOR DEPARTMENT USE'ONLY i <br /> APPLICATION ACCEPTED BY`"`.'..... : ._. _.. ------------------------------------------------ DATE ....... a ."1 N_................ - <br /> BUILDINGPERMIT ISSUED ... ..... ............... •----•-•---......-•-•--------------...........----........._.._:._..... DATE ............. ....................... <br /> ADDITIONALCOMMENTS ----------------------------------- ---------•--••--•---•--•------_. ------ -------- ........ ...........-----•--•----:.... ................... <br /> :............:..................... .... <br /> ......... <br /> ....................... ...... •. -- ......... .... <br /> Finalinspection by: ...:_ .... ----------•----------•-•--•........................•---_......_._.....................Date ....... : _ . ..! <br /> SAN JOA QUIN LOCAL HEALTH DISTRICT <br /> r w.13 24 ,.'AA 1?ov snti 7/72 3-;K <br />