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= FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................................................. . ......._. <br /> (Complete Permit No. . <br /> in Triplicate) •••••• <br /> iDote Issued .1.(`.!5.7(/ <br /> ...................................I..............__.... This Permit Expires 1 Year From Date Issued <br /> r <br /> ` Application is hereby made to the Son Joaquin local Health District for a permit to construct and install the work heroin <br /> f described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> r ' <br /> JOB ADDRESS/LOCA ...... .................CENSUS TRACT ....................... <br /> Owner's Nome Q...... ....._-!/ .+. t- �c�GY � :...... ........ . ....Phone P•7-8..-.1653..._: <br /> Address ..... ' <br /> .._.... .... <br /> Contractor's Name ............ .. ....... .:. -License .Y._;3..... Phone ._ :. .�-W.7...... <br /> Installation will serve: e'sidenceXApart ment-House f3-Commerciol-❑Trailer Court-U- — 1 <br /> Motel ❑Other .................•.......................... <br /> - .� .r� <br /> Number of living units:....._... Number of bedrooms..-3......Garbage Grinder .. .. L6t-Size .._._� X ........................ <br /> Water Supply: Public System and name ....... ........ �....... - - Y _..:...Private ❑ <br /> Character of soil to a depth of 3 feet: Sand t ilt❑ Clay ❑ 1PeaQ Sondy„L•odm ❑ Clay Loam ❑ <br /> Hordpa_r�i.}., Adobe Fill Material ... .... If yes,type ....... ............... <br /> (Plot plan, showing•size of lob, location of syst�em'�in�reln.t wells, buildings, etc. must be placed on reverse side:) <br /> NEW INSTALLATION. (No septictvon�k.or seepage it permitted if public sewer is available within 200 feet,) t <br /> f -10 <br /> PACKAGE TREATMENT ( } SEP fT C TAfJk }]� Size................................................ Liquid Depth .........:..............'. <br /> Caacity : Type ...... ............ Material._. ....;.... No. Partments ...................... <br /> Distanceto near6st: Well :. ................... ..............F lundetio?i_,� .. Prop.L-4 .-:.................. <br /> LEACHING LINE ( ] No. of Lines : . ._... length of each line .1... ............ Total Length <br /> D: dx .._.. ... . Type Filter Material .....�.....:...:....Oeptfi Fi ter`ate al , . :— :.:..._..._. <br /> D:rsti ncie to-neorf st: Well ....................... Foundation ... ...:....... . <br /> 11 :. Property line -. , <br /> SEEPAGE PIT [ ) ._WD pth t Diameter 1. Number . ._.......� _ �_ Roup Filled Yes' -No <br /> l j. ..: :._._. v.. � `' <br /> . W <br /> I� Water ciTabie Depth -----..:......................... <br /> �....... ------R k Size -:...... ........ <br /> Distane :........Fo adatio <br /> :-Lne ....... <br /> i <br /> .. .....t.. <br /> REPAIR/ADDITION(Prev. Sanitation jPer it# --....... .... ..D.-.......A... ....... ... Date -.....,.r...�..�.,.�........ /�� } <br /> Septic Tank IS}pecify Requirements) l` f'�t�Dp/--- '. . -- -�tf{!V :--.til........ <br /> " " .. 1.._....... <br /> Disposal FielB (Specify Requirements) ............ <br /> ...... ................... ............ . .. ........ ........ ......:............. <br /> f ................... ............. . . ... ...................................•..... <br /> ... --•. .....:....... <br /> ........ ........... . #......:...........` ._.....-- )---....................................... .1. ........ <br /> t{DraWv existing and_r_equired Sddition on reverse side) l <br /> I hereby certify that I have prepared this application and thatftthe work will be done in acco dance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San,Joaquin Local Health DislAct. Home owner or liceW <br /> sed agents signature certifies the following: <br /> t "I certify that in the performance of the work for which �i t i issul, I shall not employ all person in such menn*r <br /> as to become subject to Workman's Compensation law` of Cali(ornia." <br /> i ## <br /> Signed .... .......... ........... ..... ............................. Owner <br /> By .... ........................�itfe . .... .. ..: :.....:...... ....... ............................ <br /> (if o er n owner) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . _ ............... DATE ........ .................r <br /> ' BUILDING PERMIT ISSUED ................... . .... . <br /> ......................................_.... � ..DATE <br /> ADDITIONALCOMMENTS .................... ......................................••---•--............................................... ............................................. <br /> ............................. --..... <br /> i / ... <br /> .. .... ...... . <br /> Final Inspection by: ...... t.'. . ...................Date . <br /> SA JOAQUIN LOCAL HEALTH .DISTRICT WN91 <br /> E. H.L3 24 i.•r.a Qp., �qt 7/721 x <br />