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-,� FOR OFFICE USE: <br /> �u <br /> APPLICATION FOR SANITATION PERMIT <br /> -__ ---- <br /> (Complete in Triplicate) Permit No. _-7 ----------- <br /> _____________________ This Permit Expires 1 Year From Date Issued Date Issued .Jl411 <br /> bf71 <br /> I <br /> Application is hereby made to`the San <br /> PP y '%Joaquin Local Health Districrfor a permit to construct and install the work herein <br /> �,,, described._Thi application s,ma�e,in c pliance.with_yCounty_Ordjnance_No._549.and exi ting_Ru1es and Regulations:; <br /> JOB ADDRESS/L TI N _:I -- 1-- <br /> : - ------------- }---------- --CENSUS TRACT -- --------- <br /> j i <br /> Owner's Name -! - - ---V--K---------------------- --------------- <br /> -------- ---f---P <br /> i'�► ,�-I.:-t --- - hone ��_j --�----- <br /> - t - <br /> t Address G /Z----- -----_. City �� 7�f'� �7��llV <br /> - ------- -- <br /> ------------ <br /> Contractor's Name ---- ---- ----' �-- ---- --- --- ------ ------------ sF� - v --------- Phone4_(20W7'' <br /> Li�ense # 1� ��f <br /> 4 Installation will serve: Residence XApartm�t House,M Commercial❑TraEler Court. ,❑ <br /> t Motel [] Other -f--- ---------------- <br /> --------------- <br /> t.. <br /> Number of living units:Cl�._ _ Ngmber of bedrooms `� _Garbo e Grinder N0 Lot Size _ <br /> l , $ � zS-------. --- <br /> Water Supply: Public System and name ____ <br /> P ❑ ------------ <br /> ------------------------------------------ ---------' Private ❑ <br /> - ---------- ---- - --------------------- <br /> Character of soil to a depth of 3 feet rr Sand' Silt 0 Clay �egt,❑l ,5dndy Loam :❑ Clay Loam ❑ <br /> ni <br /> `Hardpan'7❑4y.Adobe) Fill Material __----______ If y s, type ________________.____ <br /> t <br /> (Plot plan, showing size of lot IocaAn of lystem-ins relation to wells, buildings, ett. must be placed on reverse side.) <br /> NEW INSTALLATION: (No se tic tan or seepage pit permitted if public sewer is ov ilable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC N j,, q � Sizer---------------- - ------ Liquid Depth ---------------------- <br /> y <br /> Capaciy -#--------------- - TYPe -------------------- Material----s.___.______-----_ No. Com artments <br /> p <br /> Distance to nearest: Well ___________________________________Foundation --_._._.___ Prop. Line --_________-____ <br /> LEACHING LINE [ ] No. of Lines ______.____. -- _-- t <br /> Length of each line---------------------- ----- Dotal Length - ----------------------------- <br /> ------•--- <br /> 'D' Box --------- Type Filter Material ____________________Depth Filter Material --------------------._______.----_________- <br /> A X14 Distance to nearest:rDia?Ater <br /> eI�7______________________ �ounda_f on Property Line <br /> ---------------- - --------- ----------- <br /> SEEPAGE PIT I ) Depth :�__._____-__-_ _ Number _______ ___________________ Rock Filled Yes ❑ No 0 <br /> 1rz 1� 4 <br /> Water Table Depth -----_�.---'----- --------------_Rock Size --.---------- <br /> ---=--------- ----- <br /> 'A � J��'�-�--_--Foundation ------ Prop. Line --------------------- <br /> Distance to nearest: ell __ ____ __________________ __-_ _ . <br /> REPAIR/ADDITION{Prev. Sanitation Permit# —- ------ -----_ -..-__ Date ------------------------ --------} <br /> Septic Tank (Specify Requirerri'ents) ------- -- �, d4-t - <br /> Disposal Fieldr(Sp cify Requre ts) <br /> --- - - - -------- <br /> --- <br /> ------- -- ----- ...�..R .�.� .. .. ------ <br /> ---------------------------------- - - <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 licen- <br /> sed agents signature certifies the following: <br /> "I certify the rn t performance of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to beco sub' ct to W rkman's ompen3 n laws of California." i <br /> ---------- <br /> ` Owner <br /> By ------- - -- -- `--c--X ------ - ------- -- -- ---------- Title <br /> - <br /> (if other than owner) !1 <br /> i 1 FOR DEPARTMENT USE ONLY <br /> L <br /> APPLICATION ACCEPTED BY ------------- - DATE -----------1 � <br /> ---------- <br /> BUILDING PERMIT ISSUED ------ ------{------------------- -----------------DATE <br /> ------------ <br /> ADDITIONAL COMMENTS ______________ <br /> --------------------------------------------------------- <br /> --------------------------------------- <br /> ' i----------- � - _�, <br /> ----------------------------- <br /> - ..: <br /> Final inspection by: __________ ___- - ---_-_-- _-- _-- -- _ _ .Date --�.__-- <br /> - ------ - ------ ------ - ---- - <br /> ------ ------------ ---- --- <br /> --- ----------- <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />