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FOR OFFICE USE: <br /> ?LICATION FOR SANITATION PERK 7 V_lyl <br /> - ...... .__ _ Permit No. <br /> ----------------•--•- <br /> (Complete in Triplicate) <br /> .�_-�.._ <br /> __--- -. This Permit Expires 1 Year From Date Issued Date Issued ?Y­ <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 /> iJOB ADDRESS/LOCATION ..-._/l.C'.t_ `- � �'' "" '` " CENSUS TRACT _._.. ._._ <br /> 'y�am�// -.____ <br /> Owner's Name ../..�!�`Lr�:../Sc {_'_�iE- L �C �L = ----- .........Phone - - ---- --- ---------- <br /> - _/—L -•----------------. City-Address .. - ---- � , - ic <br /> Contractor's Name ------- =3 f _ ..License # _I- � .ls_. Phone ------_---------- ----------- <br /> Installation will serve: Residence [Apartment House Commercial ❑Trailer Court ❑ <br /> > Motel ❑ Other --- --- -- -------------------------- <br /> Number of living units:____!-___ Number of bedrooms ---:_2>-----Garbage Grinder .. .-_____ Lot Size ..__._<2: c' ?- `_•_-._ <br /> j. <br /> Water Supply: Public System and name - - ---------- - -- ---------------- - - ---------- -------- --- --------------------------.Private [� <br /> Character of soil to a depth of 3 feet: Sand T] Silt❑ Clay ❑ Peat❑ Sandy Loam �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 ----- --- -------- <br /> .__.._._...............Ca acit . Type ----------.......... Material--------_---_ ._ No. Compartments <br /> _ Distance to nearest: Well __________________ -----------------Foundation ----- --_------------ Prop. Line -------.-•----._._._ p <br /> LEACHING LINE [ ) No. of lines . _ ----------- ---.-- Length of each line_ ------------ Total Length _.--_______________________ <br /> 'D' Box _. Type Filter Material ---------.----------Depth Filter Material .. --- -----_-------------------------------G <br /> Distance to nearest: Well ._----------------_.... Foundation ... ------ __.-------- Froperty Line ' <br /> SEEPAGE PIT [ ) Depth Diameter ....---------.__ Number --- - ___...__.._ -- Rock Filled Yes ❑ No Q� <br /> Water Table Depth ------------------ --------------------------.Rock Size ----------------- ------------- � <br /> Distance to nearest: Well ----------------------.------------- ---Foundation -------------- ----- Prop. Line _.._._.__-_-----_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•----------•------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) -._L'_4-zt --- ---- z1�- •- -----= �"'L l ®'� <br /> .� -f _f ..� rte- �.� � .''` ------ / -AL2 13------ '-�-` � '---------- -- - <br /> �ri �i _ <br /> ------------ -- -------•------••---------------------------------•---•-- ------------------•-------------•— ------ <br /> (Draw existing 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 /> s 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 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 become subject to Workman's Compensation laws of California." <br /> Signed .._ _--- -------------------------------- Owner <br /> BY - ------------------•---•---= _.-•--�-•-- -.._____._--•--_ Title --�� :•-•-•---.. -•---- --- --- -----------------. - -.. <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ------ .._ --••-•---------•--------------•----•---------------------------•------------- . DATE <br /> BUILDINGPERMIT ISSUED --------•--••--- -------- ------------------••---------•-----•---••••---.....-_-•--•--•-•----_-__••_••-.DATE --•---•---•-••---•--------•-•---------•---- <br /> ADDITIONAL COMMENTS ____________________ . <br /> ------ -• •-- f - ---- ..._..- -- ----- _= _ <br /> -- -- - <br /> "3 <br /> Final Inspection b : fid ----- E --••----••-- _---------•--.....-•••_-..Date .._ �- ---- <br /> P Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i� � <br />