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APPLICATION FOR SANITATION PERMIT <br /> .._....... ... .. <br /> (Complete in Triplicate) Cps ,�r/►/E�mit No. ......... ..--•-... <br /> ...................---------.------------------------ - This Permit Expires 1 Year from Dal*Issued <br /> Date Issued <br /> �\ on is made to the San Joaquin Local Health District for a <br /> �plicafi hereby G permit to construct and Install the work herein <br /> 'ascribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationsr <br /> JOB ADDRESS/LOCA _14/.70 _, Aw....... ....CENSUS TRACT 1.441*01FRW..... <br /> Owner's Name _ _.......... ........ <br /> - . 15� - --- -- - -- - . . . . . . . . ..... .. ...Phare <br /> Address . SRmL - - --. .._- .._. - - - -Cit _ '4 .........I ... ............ ...... <br /> Contrador's Name a7q:aJCV),&w:._1�4d '.c F't............................License # '-?1... Phone <br /> Installation will serve: Residence ff<r1m9W House Commercial ❑Trolhtr Court 0 <br /> Motel 0 Other ...................... ....... <br /> Number of living units:.. ......... Number of bedrooms .,J-----Garbage Grinder ----- Lot Size ..,.�..R ..�..................- <br /> Water Supply: Public System and name -------------------------------••---- .................------------------- ..............................Private 8' <br /> Character of soil to a depth of 3 feet: Sand 1_] Silt❑ Clay ❑ Peat❑ Sandy Loom [3---{lay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material ............ If yes,typo _............ ............ <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse d&j <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 /> Capacity ------------------ Type -------------------- Material_................. No. Compartments <br /> Distance to nearest: Well --------------- -- <br /> ..-.. .----Foundation ............... Prop. Line ...............».._. 0 <br /> LEACHING LINE [ ] No. of lines _ -__ -------------. Length of each line ... ___.._ ._ .....- Total Length ._.................. <br /> D Box .___._ __ Type Filter Material .-__ -----_.-__Depth Filter Material ..................._......-......._...... X17 <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 /> Distonas to nearest. Vlfeil _._---•---- _»___Foundation -------------------- prop. Line ........._...... <br /> ---- <br /> REPAIR/ADDITION(Prov. Sanitation Perm##.. ------------------------------ Date ....... <br /> Septic Tank (Specify Requirements) - ---------------••....... .................... ----------'----------- --.---.-----------.......__............_--•-..........1 0 <br /> Die sod Field (Specify R„irementsl1 � ..- .----------- .... <br /> -----------2-! =--��oyc?....... <br /> � ►.----------------------- .... <br /> _ --------------------------------- ----------------------- ....... . ............ ........ ------....... <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Son 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: <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 Compensation laws of California." <br /> Signed_.- _-- .--- - --- - - - - - - - -- -............ Owner <br /> �. <br /> By .- - - --- ------------------------------------- title _.1!5& ------ �c <br /> (If other an owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- --- -- <br /> --- -----------------•------------------------ --------------- <br /> ------ DATE . 7V7,9j-t IT ISSUED ----------------- <br /> _.------•---•-- .......------- ------ <br /> .-ADDITIONAL COMMENTS --------------------------- ••--•-----•-------------•-------------- - _._.. -- - - .._....-....... <br /> - ---- ------- ----- --- ---------------- ------ ------------------------------------- ................. ------ ---- -------------------- .... . . -- ------- <br /> ------------------------- - - - --- -­ -- - - - --- -- -------------- - <br /> - - ------------- ---- <br /> ER -- -- --------- --------- -•------------ ----- <br /> Final inspection by: ... _` -- - - -- - - ----- - - live <br /> 13 2�r 1-6 > V. Sk SAN JOAOM4 LOCAL HEALTH DLSTRKT 817h 3K <br />