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;R OFFICE USE: <br /> %PPLICATION FOR SANITATION PEST p <br /> (Complete in Triplicate) Permit No. ..7�. -kV... <br /> ..............._...-'-'---------------_------- ----- a/ <br /> -____ _......._..__......_-..........._.-.. This Permit Expires t Year From Date Issued 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 ex0ing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .----� - -. .�,... ___.h1�1 .�'at ,..E .� ------------------...CENSUS TRACT --------------_--------- <br /> Owner's Name 6'1 �'------------- r r+4 "---- ..........._._----------------Phone -------------------.. ----------- <br /> Address ......- --- -- - -- ---- ? <br /> IC1t- {0 � <br /> - � t . - S <br /> Contractor's Name ..... ----------------------------------------------------- --------------------------.License # ----- ----------------- Phone ------......-------•-- <br /> Installation will serve: Residence uxportment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> - -- -�'' - - -�- r � <br /> i <br /> Number of living units:---._------ Number of bedrooms ._ ..Garbage Grinde .. .J.. Lot Size -._.1. -.: -�.-trJ---__-----_., <br /> Water Supply: Public System and name ..........c:. A �-4......od-- -Llt,;,._--... �y-LC.C..............................Private ❑ <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 -------------- ------------- <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 /> PACKAGE TREATMENT.> SEPTIC TANK t ] Size.............................._-_------- Liquid Depth ------------ ............. lJ <br /> Capacity -------------------- Type ----- Material- ---_.......-_ No. Compartments � <br /> Distance to nearest: Well --......-.._-----------------------Foundation ---------------------- Prop. Line ...................... <br /> ��LEACHING LINE No. of Lines --- ----- - <br /> [a•/ �_.-__..___ Length of each line___...4:�1.�_._____ Total Length ------ ......... <br /> Box . y.�.. Type Filter Material �5;!4,Depth Filter Material ------.-2�.1............. <br /> Distance to nearest: Well -----Nr/ .......... 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- ------ --------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ._.......- -- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---- ------------------ _.--. <br /> Disposal Field (Specify Requirements) ............... <br /> Gc.Zi+_ J----._...._........... .._------------------------------------------------ <br /> ----.... <br /> (Draw existing and required addition on reverse si0e)- <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: J <br /> "1 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 War an's Compensation laws of California." <br /> Signed`..?-N - f1 --------------------------------- Owner <br /> By ---------------------- -------------------------- -- --- - ---------------------------------- Title . .... .. _--_ - ------ --------------- ------...-------- -- <br /> (If other than owner) //�� <br /> FA DEPARTMENT USE ONLY q <br /> APPLICATION ACCEPTED BY --- --- 4.�--- - �:L;;fr_e .;:,.R.- -------- - •- ----- -------------------- DATE ------ I'�� �----------- ----- <br /> BUILDING PERMIT ISSUED ------_--- ' _-------- =K--•------------------------ --------------------------------------.....DATE ...--------•---------------------------- <br /> ADDITIONALCOMMENTS ------------------------ ---------------------------------------------------- ----------------------------------------------- ......... _---------- <br /> ------------------------------ <br /> ------------------------------ --- - __ - . - - -------------------------------------- __-------------------- --------- -- ------------------------------------------------------ '--- <br /> -..------------------- - ---------- <br /> Final Inspection by- ---------------_. - - -- --- <br /> - ----------•---------' -- --- -- -- --- ------...- - - -- --- --'------Date ------------ <br /> SAN <br /> - .....-'--------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />