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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Tri�lieate) <br /> Permit No. r / <br /> t This Permit Expires 1 Year From Date issuer! Y G-7.f <br /> ........................ Date Issued .91. .......... <br /> -51 ((00,-e <br /> Application is hereby made to the- 00 <br /> San Joa uin Local Health District for a permit to construct and install the w <br /> ork <br /> described,This,application is•made in.compliance with County Ordinance No. 549 and existing Rules and Regulationsrein <br /> Z3Z3, c�_ c I <br /> J 13 AbDRESS/LOCA ?4 > � <br /> cf <br /> ����. _... . !.. _`�'....... w .CENSl35 TRACT •................. <br /> Owners Name .. w•-,.. . <br /> Address t ........Phone ................. <br /> +,r- :..CI <br /> . ..... <br /> .......... <br /> 57 <br /> Contractor's Name .... ; license ~. <br /> _:` -•-- -- :..-Phone <br /> Installation will serve: Residence[3 Apartme usao Commercial[]Trailer Court 0 <br /> i <br /> Motel [�Other <br /> ..n. ._•_-.tee. a.�...' <br /> Number of living units:............ Number of bedrooms ___._._,,,,,Garbage Grinder ..........._ Lot Size <br /> ................. <br /> Water Supply: Public System and name <br /> ..........................................................Private <br /> Character of soil to a depth of 3 feet. Sand EJAi it[] Clay Peat 0 Sandy Loom ❑ Clay Loam <br /> Hardpan t,JJ Adobe C] Fill Material <br /> If yes,type= ---- <br /> (Plot plan, showing size of lot, location of. system in relatiori to wails, buildings, etc, must be placed on reverse side.) <br /> { NEW INSTALLATION: (No septictank or seepage pi# permitted if public sewer is available within 200 feet,j <br /> Size.. <br /> �. <br /> PACKAGE TREATMENT { ] SEPTIC TANK{ .....__._ liquid Depth <br /> .. .............. .- <br /> .. <br /> ...... .. <br /> OW......_•............. Type ......._......--- Material_.. No. Compartments' ..... ---.•Distance to nearest: Well ............ dProp i <br /> LEACHING LINE [ ] No. of Lines <br /> ............•........... Length of each line........................ Total length ' <br /> 'D' Box .... Type Filter Material Depth Filter Material <br /> I <br /> Distance fie nearest: Well ......:____________ Foundation •Property Line -. <br /> ...... <br /> SEEPAGE PIT E 1 Depth N <br /> . Diameter ... ....,... Number ............................ Rock t=illed Ye <br /> Water•Table Depth .........Rock Size s <br /> No , <br /> Distance�to nearest: Well ........................................Foundation .................... Prop. Line <br /> REPAIR/ADDITION(Prew Sanitation Permit#.................................... bate <br /> Septic Tank {Specify Requi�ements) ........... - .......................] <br /> Disposal^ Field (Specify Requirements)_ <br /> _ .. <br /> w t <br /> ...........................-................_......................................................... <br /> ._......... _..... ` .. <br /> ...dd...........i ....................•__-_........_........................................._.....� <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared that application and that the work will be done in accordance with San Joaquin ' <br /> County Ordinances, State lows, ani) Rules and Regulations of the San'Jeaquin Local Health District.home owner or (jean. <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work foe which this permit is issued, I shall not emplar any person is such,nannir <br /> as to betome subject to We an's Compensation lam*of California." .. . <br /> Signed ........................... ...:. ...... Owner <br /> ...... --•- <br /> By------- ................... �`-!r <br /> .. <br /> . ....... Title <br /> (If ether than owner) .. .__..-...&zr­:••._. .:.:. .............. , <br /> hFOR DEPARTMENT USE ONLY <br /> iI <br /> APPLICATION ACCEPTED BY:,-,•,-••-,•, - <br />' BUfLDING P r....................... _..._._.. •-:...._..........._...--.--.... <br /> PERMIT ISSUED � DATE ......... ..r(,._ 7f <br /> ADDITIONAL .. ...... ............... <br /> ONAL COMMENT5 ............:..DATE . <br /> ................................ .......::::, � . ..__ :...................................... ...-_ ........._......... :.:: ::::... <br /> ....................... <br /> .......................::: :.:::::::::::::..:,,:++:.. :::::::::::::::::::::..:.::::::..:::::::::- ...:::::.:::::::............:.::::....... .....:......::::::::::::::::: <br /> final Inspectionby: ..................... ..h. ........ ..................._..... ..... _....._.._..... .......... <br /> •---•---....._---•------_.....----•.................................Date <br /> 7 ......... <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> E. H.13 .24 1-'88 Rev. 5M � <br /> ....SAN <br /> " ' . - x• ._.._. �..,..�. _ <br /> 7I7�'� ar <br />