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FOR OFFICE USE, -, <br /> -�- --- ..o- Ali , <br /> APPLICATION FOR SANITATION PERMIT <br /> ................:................... (Complete in Triplicate) Permit No. .7. ..::3:q S <br /> ,.,......_............... This Permit Expires 1 Year From Date Issued Date Issued .'.`....�... �7.y <br /> I <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 /> JOB ADDRESS/LOCATION ...I/.----- ---./L-- y.__�lzd......... . . ...........................CENSUS TRACT ...5�.` ....... ..... <br /> Owner's Name ...... .1 ... <br /> . -LAX;1-2___1a <br /> ......-<-... Phone -................................. <br /> Address _........_...---- F1/ ...........::� e,.................-.... ...... .............. City --- - _ .---...._.._.._... .-_-......--....--.-...-...-..... <br /> Contractor's Na00 ' - . . .............._.......License # ......... -------------- Phone .............................. <br /> Installation will serve: Residence❑Apartment House 0 Commercial Proller Court <br /> Motel ❑Other ............................................ <br /> Number of living units:..... ... Number of bedrooms ............Garbage Grinder ----- Lot Size .......................__.............. <br /> Q// <br /> Water Supply: Public System and name ..._............................................................................ ..............................Private <br /> Character of soil to a depth of 3 feet: Sand o Silt❑ Clay ❑ Peat❑ Sandy Loom Clay Loam 0 O <br /> Hardpan-❑--Adobe•❑—F(IFMaterial:.-=-- If-yesrtype__.:_..,:...._ <br /> (Plot plan, showing size of lot, location of. system 'fi relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ J SEPTIC TANK np Size---3 ..T_.lAl.................._. Liquid Depth __P................ <br /> Ca acity;../A--.._.,Type,.�T�_. �Nf�Material_...Ce�G.: No. Compartments ...:.;............. <br /> istance to nearest: Well ..............................---._Foundation .............-........ Prop, line ........ <br /> LEACHING LINE No, of LinesJ.....�w............. Length of each line------ OO._.......... Total Length .. O Q <br /> 'D' Box ..../___ Type Filter Material ---L4..f9.�_.._-Depth Filter Material ...........'/...� .�....._--....... <br /> .-.. 4 <br /> Distance to nearest: Well .... Foundation ..1Q.. ..... Property Line .....1 - <br /> r <br /> SEEPAGE PIT [ Depth .... ..........._.. Diameter ................ Number --------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth -----------------------------------------Rock Size .............'......-•------- <br /> � <br /> Distance to nearest1 , Well .......... .............................Foundation ...._............... Prop. Line ................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ................................... Date ....-............................ <br /> ) - <br /> Septic Tank (SpecifyRequirements) .------------------------- , <br /> Disposal Field (Specify Requirements) ----------------..................................................................::---------------------- ----------------------- <br /> -------......_....._...._........-------------------i----------..................................................--`---'-----._......._.....-........-_--• ..................... <br /> t <br /> —(Draw ekisting and-required-addition-on-reverse-side) <br /> I hereby certify that 1 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 Son Joaquin Local Health District. Home owner or licew <br /> sed agents signature certifies the fallowing: <br /> "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person In such manner <br /> as to became subject to Workman's Compensation laws of California." <br /> Signed ................ <br /> ------- .. Owner j <br /> . ............................................ <br /> By ..... ....... Title ......... .. ................................. <br /> (if other than <br /> •i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -...... -rs/----.-------------------- <br /> .... <br /> . ......................................... DATE -...... ... <br /> `h�--7. ..:.-....--. <br /> BUILDING PERMIT ISSUED ................................ ....... ................... .........-....._........_:..............DATE .-. ....-..-...-............ --...--- <br /> ADDITIONALCOMMENTS .............................................................................-............................................. -- ...I------..-.................. <br /> ----------------- - - - ,- -- 1„/------------------ ..._......:_..........-.... - - - <br /> . .... ... ... .- <br /> - -_ - <br /> -' - ................................................. <br /> �.. .. { F __.._.-.-........Date ...... ...................... . <br /> Final Inspection lsy:--: ..f.��-.�............. ...-.--....... �. ....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E u 13'241-uaoe,, qeA 7/723M N <br />