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FOR OFFICE USE: PPLICATION FOR SANITATION PE ,IT <br /> :.... --------------------------- --- Permit No. _22:-(_ <br /> (Complete in Triplicate) <br /> P. This Permit Expires i Year From bate Issued Date Issued ��a__. <br /> i` Applicotion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> -�; <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 4 ' <br /> - JOB ADDRESS/LOCATION p- 1._. Y_.. e•-Q � ----------------------------------------------- CENSUS TRACT ..5.�. <br /> Owner's Name .._ ---------'-•-•..........:............•.... ...._.-........_...,.......---••-- .................. Phone _9.31,-Z511.............. <br /> i6 Address ._-.. ------a�P................-..........................................................----•-.. City ..........L.�1d1....................................................... <br /> Contractor's Name ...- 3-e-pt.�.G---T-ank------------------------._:License # �c'>�•Q`��•• Phone J.i��--����- :...... <br /> Installation will serve: Residence Zj Apartment House Commercial ❑Trailer Court 0 <br /> 0 <br /> V Motel ❑Other --- ------------- <br /> I it <br /> r <br /> Number of living units:_.__ 1._ Number of bedrooms ...Garbage Grinder ___- ....... Lot Size ----------4--- x ................ <br /> y Water. Supply: Public System and name -------------------------------------------- ------------..........----- ....................... .............Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam D <br /> i1 Hardpan ® Adobe ❑ Fill Material ------------ If yes,type ________________________•--- <br /> (Plot 1plan, 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 /> ' <br /> ' PACKAGE TREATMENT [ ] SEPTIC TANK-[ j -Size------------------------- -------------------- Liquid Depth ..........._•-----------•-� <br /> - - o <br /> Capacity ------- -------•--- Type _--------•-------- Material...................... No. Compartments ...._....-............= <br /> it <br /> 'Distance to nearest: Well ..................Foundation ______________________ Prop. Line ........ <br /> LEA61NG iLINE ] No. of Lines I------------ ---- Length of each line-- Via'_....-------. Total Length ---.`4:Q_E:_.__...-__: <br /> _- -- - <br /> _._.. <br /> ' r71•9!: ---•---- <br /> T ! 'p' Box ------.1._-. Type. eilter Material .............2-"--.Depth Filter Material ---------- ---..... <br /> ..... <br /> �-` �Distance.to nearest: Well ------5r _ z----_.......Foundation c Property Line ____5.0.1 <br /> SEEPAGE PIT j Depth. ._.25'---------- Diameter, :- ..F-"__ Number ...... .................... Rock Filled Yes ® No ❑ <br /> EiWater Table Depth *_ Rock Size ...2.'.'------------------- O <br /> y Distance to nearest: Well----------1� -------_ -------------Foundation ------------ <br /> r? <br /> ---�:---T..._..... Prop. fine _.U.'............ <br /> rREPAIItjADDITION(Prey. Sanitation Permit# ------------ -------------------------------- Date .............................. <br /> + Septic Tank (Specify Requirements) __________________ .. .. -••••-•----- <br /> Disposal Field (Specify Requirements)�-Q-----Le e----------n--.-�---p��- "X2�.e- --------------------- <br /> _--` f'_.---.-- - --- --------------------- ---- <br /> ----------­-- -••--•--- ...................• <br /> (Draw existing and required addition on reverse side) <br /> I herleby 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: <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 toIibecome sub)cct to Workman's Compensation laws of California." <br /> { <br /> Signed ....... •------•---- --•---•- -------M1--�---••.................... .. . ................•-•- Owner <br /> " ;� <br /> I! �BY --.'�...._- .�.,:--��....-.-. �rl-�.- --.. -_:��f... ..................... Title -------- ...................-......... <br /> : <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> F �°•� <br /> k� APPLICATION ACCEPTED BY .... _ ..... ....•••...............:............... ...................... DATE ... y --------•-------------- <br /> BUILDINGPERMIT ISSUED .-----•---•-•-•-----•---•--•--------------•--•--------•--. ---------------------------------DATE ...... .............I--------............... <br /> ADDITIONALCOMMENTS ............................................ •--••--•--•••-•-•-----•---...-------•---.... .. ---------•--------_-•---------------- .-_...._..._ <br /> i-i .• i+.. _ .. :Y ...................••. - - <br /> -- <br /> .---:_._.__.r-.....-- - ...................... ---• r� ................. <br /> Final inspection by: _..". .. Date 1......_._ . <br /> --•----------------------•-. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I N <br /> 1 q <br />