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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> T ...... ......... Permit No. . --/d74 <br /> (Complete In Triplicate) <br /> r .............---................................. <br /> I Dare Issued <br /> +..-_............... ._. -__.__-_____.--••__--•-- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance Na. 549 and existing Rales and Regulations: <br /> /I -7 B o --A- YY tO IiF�9 <br /> IS •� men. �'.�- ,� '� j' CENSUS TRACT ...........JOB AQQRESS/LOCATI N ......-...-----------...--:-...--••---•.............. . ....-....... . <br /> E .. <br /> Owner's Name ----- 1�''.................................� :............................. �. ... ...._...... _3 ................ <br /> �r . <br /> Phone <br /> 14' <br /> Address ... .f� �....lT. ........ .......... .......•- . CifY .....__... <br /> y d <br /> Contractor's Nome...........(c?, . �.. --- 'r�---- �`::..........License # .Is 3 �.. Phone .............................. <br /> i Installation will serve: Residence ❑Apartment HouseE] Commercial IFTrailer Court <br /> Motel❑Other -----------_- ---------- ..... <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ........._.. Lot,Size ....._...,..,..........._.._.. ........ <br /> `w Water Supply: Public System and name ------------------------_------------------------------- - ... ----•--• ..................-...............Private <br /> -, Character of soil to a depth of 3 feet: Sand'[] .Silt❑ Clay ❑ Peat❑ Sandy Loom E) Clay. Loam Q <br /> E Hardpan ❑� Adobe fIlLMaterial.............. If es, type _. <br /> Y e -••-.... ........ <br /> (Plot plan, showing size of lot, location of..system in relation. t6 .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 204_ feet,):. <br /> PACKAGE TREATMENT [ ] SEPTIC-TANK Sloe. 1.�/ s -�----....... Liquid Depth ..... ................. .. <br /> Capacity 1 -n yp c . No. Compartments ....._ <br /> ' T e C� �.... Material.. -�� ....,_.. <br /> Foundation <br /> Distance to nearest: Well l0.__. fi ...._1.D.---_...:_. Pro Line <br /> v . Total Leii i <br /> LEACHING LINE [� No. of Lines ........•................. Length of ,each line----:-- ____..._-•--••-:- gth -..'a..._._.._....:--:� <br /> 'D' Box _fr.------ Type FilterAciterial ..5. ..........Depth "filter Materidl �Y�..................---.. -- <br /> 3 <br /> - :_.1--0-=......-- Property Line...-.----`'r-:.. <br /> Distance to nearest: Well ..-/b�?.�....:. Foundation � ...=•--•-•�=�i <br /> [ ) p ...:------=--:.... Diameter Number -- - .::• Rock Filled Yes.0­ No <br /> OE <br /> SEEPAGE PTT Depth - <br /> • Water Table Depth ....:...............Rock Size...... --- , <br /> Distance to,nearest: Well -_-.•................................. Foundation'.---,-----_...-........... Prop. Line - ------..-_-- ID <br /> ' REPAIR/ADDITION(Prey. Sanitation' Permit# ....;•--•-...................---........•••. Date _.-_•_•-___......-: ............ <br /> SepticTank (Specify Requirements) ----------------•------- -------------............................................-....... --------•--........ -------- ................... <br /> M Disposal Field {Specify Requirements) __:______._ <br /> 4 i -----------------•-=--- ••-•--. --------------------------,- <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 San Joaquin <br /> 1 County Ordinances, State Laws' and Rules and'Regulations of the San Joaquin Local"Health ,Diarict. Home owner"or licon- <br /> sed agents signature certifies the following: - <br /> 4 "I certify that in the performance of the work for which this permit is issued, I shall not employ any persons in:such manner <br /> as to became subject to Workman's Cornper4cition laws of California.." <br /> F4Signed --- ----------------- _.._--•---=----•-----.-.. .. -........_............................ Owner <br /> � !��--- .._ Title {- " <br /> 8y .. ........::...•--- --._...:. <br /> (if other than owner) <br /> /� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...�„�^- .......................:............. •-•-•--•..... DATE ." ~ .: <br /> BUILDING PERMIT ISSUED DATE <br /> ri ADDITIONAL COMMENTS .....................- --------------------------------------------------------------------------=---• --•----=------ -....----•--- -.-------....-•-------- <br /> F �' - - .. - _ ----------------• ......_----.. ................. <br /> ---- '............. <br /> ....................................................... <br /> -•.....--..••-__ -••_ .....•_.. - •_•' - ••-•- --_ •• _- .. ...... ..............................- .... •• ....... ` � - - ...... <br /> ............ <br /> ....... ........... .•, - - <br /> Final Inspection by-.-__ ® " ;a- ..... ................................ ..-- ....._...Date _. ;7,3-i- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />