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FQR OFFICE USE: <br /> / <br /> APPLICATION FOR SANITATION PIAT <br /> ..... ...... ( I <br /> >C - -� -1*4 '3 <br /> . <br /> lComplete In Triplicate) Permit Na. ........I....... <br /> ----------...................4...... ................ <br />. ............. ...................................... This Permit Expires I Year From Date Issued Date Issued .................... <br /> he San Joaquin Local Health District for a permit to c struct -1 'Stbil the.-'work herein <br /> Application is hereby made to t on I <br /> described. This application is�6 �� <br /> de in compl1q;kCe,.with County Or finance No. 549 and existing Rules and 6gulations.. <br /> JOB ADDRESS/LCI <br /> CA ............. <br /> T <br /> G _L'f . ............ . .................CENSUS TRACT ........ <br /> Owner's Name ....... ........ ... .. <br /> ........... ................... .... one <br /> Address <br /> ----------- City ----- ................................................... <br /> .............. . <br /> -,Liz <br /> _..License # ................ ....... Phone <br /> ---------_------------I............... <br /> Contractor's Name <br /> Installation will serve: ResidenceAApertment House 0 Commercial OTraller Court <br /> Motel C]Other.........._ '_g......................... <br /> ......*"'*'*'**....... <br /> Number of living units:.. Number of bedrooms Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ........ ................................ ..................................................................Private <br /> Character of sail to a depth of 3 feet: Sando Silto ClayE] Peato Sandy Loam o Clay Loam,� <br /> Hardpan 0 Adobe 0,Fill M6terlol ............ If yest type ............... ............ <br /> (Plot pion, 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 TAW&,� ize......E-A. t................... Liquid Depth <br /> .. ..... ....................... <br /> r � -2 <br /> Capacity --I __.: Ty pe . ... .... Moteriold2. .. .... No. Compartments -- -------------- <br /> Distance. to <br /> . ..............Distance. to nearest: Well ------- ...........Foundation Prop. Line ------ <br /> LEACHING LINE No. of Lines ......../... -------- Length �o each .......... Total Length ...... .......... <br /> 'D' Box .../.... Type Filter Material <br /> -_. ..._mac Depth Filter Material ......._/46............... ....... <br /> Distance to nearest: Well .... --- Founlation ......Is ---- Property Line ..... <br /> SEEPAGE PIT Depth ... Diameter --------...... Number ........... ./_ Rock Filled Yes 2�, No 0; <br /> /,-- — �Jvx_ �/Z__- <br /> Water Table Depth ..._--------- z( .............Rock Size ...................... ........ <br /> ell <br /> Distance to nearest: Well --- ........................Foundation ... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# <br /> ..............•---•-----•--•---........----- Date .................................. <br /> SepticTank (Specify Requirements). ..--•--•................•------•--.... ........................................... .................................. <br /> Disposal Field (Specify Requirements) ------ ___=7--•................ ....... <br /> ------------------ ..... .........................................I............ ..............I......... <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 111cen- <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 sub' ct to Wo laws f lifornio." <br /> )Ic4an's Compensatio <br /> Signed - 7 �__ L'�A —__ ebnww <br /> ---------- ---- -----r. ........I�--- --- ------- 6t <br /> By -------------------------------------------------------------- .................. Title------------------­ - ..._^...-..................... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ON_ <br /> ----------- <br /> ------------------- - - DATE _&...... <br /> APPLICATION ACCEPTED BY ...... 71 <br /> BUILDING PERMIT ISSUED ......................--.-----•---.._.....---•---...... ...._.. <br /> ................................. <br /> ----------------------------------------- <br /> ...... DATE .. ....................................... <br /> ADDITIONAL COMMENTS .............................I....................... .......-------- ............... <br /> .......... . ----------------- --------------------------------- ... .....I-------------- --------------------------------------------- .......................................... ------ <br /> ....­.............. .........•---•----........ ---------­---- -------------------- ------ ------- ----•--•-•-....•-------• ------------------------:...--- <br /> ------------------*------------------------------ <br /> ............................•...-------. ---- ;2------------------------------------------------------- _,"2 <br /> ............. .ate ........ . .. .... <br /> at, <br /> Final Inspection by. ................... .. ... ... ............... .. <br /> M4 13 21a .1-68 Rev./5� SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />