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FOR OFFICE USE: <br /> WLICATION FOR SANITATION PF 'IT <br /> ..................................................... Permit No.e.*.F."'�7_-3 <br /> (Complete in Triplicate) <br /> Date Issued .16/-1-d"-�� <br /> -----• This Permit Expires t Year From Date Issued <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 ._` _ _ �� .---- - --..._ _. _�LNZAI-*------- ---------------- ---CENSUS TRACT _....----------•---------- <br /> Owner's Name ...._.. _Phone __ ,.23..-_ 662( - <br /> Owner's �'� U-w-----------•--------------------- �' <br /> Address ..._. A -----._---"------------- ------------------•------ -. City _ C •--•----------------------•--•---•-- <br /> ...----- <br /> Contractor's Name --------© !_!(1 / ..................................................License # -----------------------• Phone ............. -------.-.---•-- <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other --------------------------------------- ..... 1 <br /> Number of living units:....... .-. Number of bedrooms ...—.-,J_...Garbage Grinder .. Lot Size ..�pl- � " <br /> Water Supply: Public System and name ------------------------------------------------- ............................................................Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam El Clay Loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes, type -"_____________"___--__.._.. <br /> (Plot plan, 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 TANK T ) Size------------------------------------------------ Liquid Depth ­-------- ----------------- <br /> Capacity -------------------- Type -------------------- Material...................... No. Compartments -­--------------- - <br /> Distance to nearest: Well ------------------------------------Foundation -_.-_.._.__--.-------- Prop. Line -..._...--...----"------------ <br /> LEACHING of each line--------------------- ------ Total length --- - ------ <br /> LEACHING LINE [ ) No. of Lines .............----------- 9 <br /> Depth Filter Material ______________ -"---"--- <br /> 'D' Box ___.._.--"-- Type Filter Materia -------------------- P <br /> Foundation Property Line - <br /> Distance to nearest: Well ________________________ -----------•---•-•------ <br /> SEEPAGE PIT Depth Diameter Number ............................ Rock Filled Yes ❑ No 0 <br /> [ ] p -------- ------•---- •--------------- <br /> WaterTable Depth ------------------------------------------------Rock Size -----•--------------------..---- <br /> Distance to nearest: Well ......................... <br /> -----------------------------------Foundation -------------------- Prop. Line --------.-----•-.-•-•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --- / <br /> Disposal Field (Specify Requirements) -------------- -• •---- <br /> ----- - <br /> - ------------- <br /> (Draw existing and required addition on reverse si e <br /> no in r <br /> uin <br /> I hereby certify that I have prepared Rules andthis 1cation and Regulationsthat the work will be of the San Joaquin Local DistrctnHomewith <br /> or licen- <br /> sed County <br /> ordinances, State Laws, <br /> sed agents signature certifies the following: person in such manner <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> as to be a bj Work 's o pensation la of California." r <br /> F <br /> .-.-__. Owner <br /> Signed <br /> ---- A� <br /> j `- Title ----------- ------------- j�(�'"f- -+/ <br /> "----- -- -- ------ . l�'� <br /> B ------- -- �1 <br /> y (If other an owner) FI T, R <br /> OR DEPARTMENT USE ONLY <br /> DATE1/0� •- -•-•---•----- <br /> APPLICATION ACCEPTED BY ---------- ---- - <br /> DATE -----------•---------•-----------------•--- <br /> --"--••- --•"--•-•"--•---•-"•---••--------------•---•---•- <br /> BUILDINGPERMIT ISSUED -------------------------------- ---- ...._:._...._.._....--•---------- <br /> ADDITIONAL COMMENTS ---- -------------------------- <br /> -•----•-•----------••--•-------•-••---•-•-----•------•"- ----------•--•---- <br /> ------------------------------ - -- ----- <br /> Date -------------------------------------------- <br /> ---- <br /> / Final Inspection b --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> W 0 1.'hA Rev. 5M <br />