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_ n <br /> FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT <br /> i'.F.--..;�....._.f� _........... <br /> Permit No. ............. . r <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued •-7--2..1 .... <br /> Application 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 /> JOB ADDRESS/LOCATION .. �. �! `� t ......CENSUS TRACT <br /> E 7 IO2Sfd <br /> Owner's Name - = <br /> ---... ...�.�.............. -----•-----�.. ....... • ,---...... ..Phone.......... •-- <br /> Address .._.... � ��BL.�.....: v -: :C`.!�.. ~...... City ....dl ( 'KtQ ----------- --------------- <br /> License # Phone .......... .... <br /> ( Pn ! .. �o` ��f..... y �s�i-3y3 <br /> Contractor's Name,_.• _. ..._..... <br /> -Installation will serve� � Re- silence-Ee�p ra tment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other <br /> Number of living units:...f... Number of bedrooms ..._._ ....Garbog a Grinder ------------ Lot Size ............................................ <br /> Water Supply: Public System and name -------.................................................._....--•••--•----......------------------•-------•...Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 . Slit❑ Clay ❑ Peat❑ Sandy Loam fl Clay Loam ❑ <br /> Hardpan ❑ Adobe [g—Fill Material --..--.-.... If yes,type ............................ <br /> f <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> k <br /> NEW INSTALLATION. (No septic flank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Siae................................................ Liquid Depth .......................... j <br /> Capacity .. Type .. Material .... No. Compartments ...:......... <br /> fDistance to nearest: Well :-:!• •--• .--•r' ---------Foundation ...................... Prop. Line ..................... <br /> t y <br /> LEACHING LINE-' [ ] No. of Lines ........................ Length of each line............................. Total length ............................ <br /> -s 'D' Box ............ Type Filter Materia{ ..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 ...Rock Size <br /> Distance to nearest: Well ........................................Foundation ... ......... Prop. Line ...................... y <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date .-..----.._.._.....--•-•-----.---.) <br /> `1 <br /> Septic Tank (Specify Requirements) 1 2pCi G Arc. Pc. Ilsn1 -- _.. <br /> Disposal Field (Specify Requirements) ......YQ_....0E e% .... � w.J.__.�31•! ........33._X.... .........Q ........................ <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, 1 shall not employ any person in such manner <br /> as to be a subiect to Workm 's Compensation laws of California. <br /> Signed .. -VIA...... -----------•---•-•--•----•-- Owner <br /> By ........ .... : ......... . Title ...............................................,:......---- :_...: <br /> (If other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ...... ................... ................... --. ................... •-----------_----•--. DATE ..... ....... ;?7!7`71/. - _-..... <br /> BUILDING PERMIT ISSUED .................................................... .....................................:..............DATE ....... <br /> ADDITIONAL COMMENTS ..............:. <br /> ............... ............................................ ------.... ........... ............. ....... .................................................................... <br /> ......................................... . . ........ ..... . -----------------..........•.... ............... <br /> Date <br /> Final inspection by: . .. ............................................................. r.,�.r... <br /> SAN JOA IN IOCAL HEALTH DISTRICT <br /> �.. wk__� 7/72 3 m <br />