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Y <br /> FOR OFFICE USE: -� ° <br /> APPLICATION lOR SANITATION PERMIT <br /> Permit No. <br /> --- <br /> (Comple?e in Triplicate) <br /> ---------------------------------- ----- <br /> Date Issued -_. `f <br /> ----------------- This Permit Expires 1 Year From 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 /> / i <br /> JOB ADDRESS/LOCATI N --L f - -- ----- ' _` E- ENSUS TRACT ----------- -------------- ` <br /> Owner's Name '----- 'G�/-�"�'/�/-�'aI�..5------ -------•------------------------- ----=--------------------- 1 <br /> Address --- '�,�f ��----/U- CiL .oJ Q.L- �-�+. 1�City , , <br /> Contractor's Name --L'r`� 5 -� r� 5 � 1.0 --------------License # I2.Z.-f-�r.1- PhoneW-9,177_Via.-r�✓� i <br /> 4 <br /> Installation will serve: Residence &Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ------------------- ------------------------ r i <br /> Number of living units:----- --__._ Number of bedrooms -------__-Garbage Grinder .-AtO.- Lot Size '----------------------------------• <br /> Water Supply: Public System and name ------------------- ------------------------------------------------------------------------------------------Private ❑ <br /> 4 <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 ---------------------------- 4 <br /> � 4 <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 /> ati <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;( ] Size-------------------------------!----- - ------ Liquid Depth ---------------------------- <br /> Capacity <br /> .-----Capacity -------------------- Type -------------- ----- Material---------------------- No. Compartments ------ <br /> Distance to nearest: Well ------------------------------------Foundation ---- ---y--- Prop. Line -_--------_--------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of.-each line------------------------.-.- Total Length ------------__----------- <br /> 'D' <br /> -----.---------•----------- <br /> 'D' Box --------- -- Type Filter Material ,'�-- -_----- <br /> Depth Filter Material -------------.------•----------- <br /> _� . <br /> Distance to nearest: Well----------------' =Foundation --.--------------------- Property Line -.--_------- <br /> -- Rock Filled Yes No ' <br /> SEEPAGIr PIT [ ] Depth -------------------- Diameter ---------------- Number -----`------------------- ❑ <br /> Water Table Depth ---------------------------Rock Size -------------------- ----------- <br /> Distance to nearest: Well -------------------------------------...Foundatidn -------------------- Prop. Line ---------------__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---- t---•---------------- ------------------- Date -----------1k ---------------] <br /> Septic Tank (Specify Requirements) -------------------------------------------------------F--------------------------#---------------------------_----------------------------- <br /> i <br /> Disposal Field [Specify Requirements] ----- 5V 0 <br /> - <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. Home owner or licen- <br /> sed agents signature certifies the following: tt <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 becorn subject to Workman's Compensation laws of California." <br />- . Signed -- --.---------- ------------------ -------------------- ------------ Owner <br />' BY ---------------------------------- ------- -- --- --- ---- Title ----- ------------------------ --------------------- ------------------ <br /> (If other than owner) l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------- -------- -------- -------------------------------------------- DATE -- ----- <br /> BUILDING <br /> ---BUILDING PERMIT ISSUED --------------------------------------- --------------------------' -------- <br /> -------------------------------DATE ------- ------------------------------------ <br /> - - <br /> ADDITIONALCOMMENTS ------------------------ -----------------•----=--------------------------- <br /> ---------- ---------- <br /> --------------------------------------------------- ------------ <br /> -------------------------- <br /> -------- <br /> � -- - -----k4 <br /> -- - - - - - - -- ---- --- ---- ------ - ------- <br /> ------ <br /> ------ <br /> - __ ------ <br /> -- - r - --------- <br /> ------------ <br /> ------ -------.DateFinal Inspection b -------------` ' SAN JOAQUIN LOCAL! HEALTH DISTRICT <br /> t <br /> f <br /> E. H. 9 1-'6$ Rev. 5M <br /> �ox <br />