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R <br /> , • r y. <br /> FOR OFFICE USE: � <br /> i ... APPLICATION FOR SANITATION PERMIT <br /> .............. ---------------------- }x e - F'S� <br /> (Complete in Triplicate) Permit No_ ______________________ <br /> r i Date Issued /.---- =--�� <br /> ---------`� 7------------------------------------tc..- This Permit Expires I 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 /> cies <br /> 'Cribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __________________________CENSUS TRACT .__-____---_.------___-_ <br /> U. <br /> Owner's Name �/ Ay.. L----------------------- -------- -- <br /> ., .b...4c . <br /> ---- . .........Phone e <br /> ' ,1 � . ......................CityAddress <br /> ry <br /> Contractor's Name ------ ✓-------------------------.-----.----------.--------.License #L4 (i?. Phone <br /> -------- <br /> _ <br /> Installation will serve: Residence 14'A-Partment House❑ Commercial []Trailer Court '❑ �����, <br /> IMotel ❑ Other - --------- ------------- ---------------- <br /> Number of living units: Number of bedrooms ------- Grinder Lot Size' C��'-��' ..__________ i <br /> 1 � <br /> Water Supply: Public System and name -------------- --------•---------------------- <br /> ---------------_----------------------•--------------Private [� <br /> Character of soil to a depth of 3 feet: Sand*ilt❑ Clay ❑ Peat[I-'- Sandy Loam ❑ Clay Loam &I <br /> Hardpan ❑ Adobe ❑ Fill Material ___. ------- If yes, type ............................ <br /> i <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 seeps pit permitted if pupJic se er is available within 200 feet,! `���{ <br /> PACKAGE TREATMENT—[,]'. SEPTIC TANK [ Size./._. X' ..X _.---- Liquid Depth ..T-�_----+--.._ <br /> ' ' <br /> � <br /> r""!'� Capacit#)�PAP_---- Typ -F-W- MaterioVx�.�WNo. Comparttnents - . .. <br /> / Distancefto nearest: Well _._.f6_A _. __ ._.-------Foundation ..�0._.`__._..___ Pr p. line . ....... ........ 00 <br /> 41 <br /> LEACHING LINE [��Na. of Lines .. ........ .. ... Length of each line--_/... Total Length .... ......_.-- <br /> ( D' Box ._.___._.___ Type Filter Material Pi r- '_.�_ .Depth Filter Material --} ---------------------- .._-_--- <br /> Distano+ to nedrest:'Well".4 Q0---------.__ Foundation _./Q_:...""".`Prdperty L'irie --------­------------- <br /> SEEP GE <br /> _.-_-_-. --_SEEPAGE PIT [. ] Depth ________________ ___ Diameter --- <br /> ----- _. Number ... ........................ Rock Filled Yes ❑ ` No ❑ V ' <br /> f <br /> Water Table Depth --------------------'' ..Rock Size . .... .------------------- 0 <br /> ft}1i Distance to nearest: Well ----.-_.. lU-------------------------Foundation ...........2. Prop. Line ....................... <br /> REPAIR/ADDI116N(Prev, Sanitation Permit# ....................:....................... Date -----------------------------------I G� <br /> Septic Tank (Sp y 9 --------------•----------•-------------------------� - <br /> -----------•-••---•......I--- ---- ---. .----.--- <br /> eaf Requirements) ................................... . <br /> _�... I r . <br /> Disposal Field (Specify Requirements) ------------ ................ ---------- ---------------- - ..... ........ <br /> �. <br /> f �--- <br /> (------------------t----------------------��-'r----- ----------- -----------•---•----._ --- - <br /> .. ....... <br /> (Draw existing and required addition on reverse side) r . ; <br /> I hereby certif ha�� ave prepared this ap¢liiation and that the work will be done in accordance with' San Joaquin <br /> County Ordindwces,�5tct's Laws, and Rules and'Regulations of the San Joaquin Local Health District. Home owner or (icon- <br /> sed'agentsiigh,ature ce'r ifies_yhe following:---^---�----- ----•- ---- --- - - ---- I ' <br /> i <br /> "I certify that irrthe performance of the work for which this permit is.issued) I shall•not--employlany person in such manner <br /> as to become shbject to Workman's Compensation laws of Califa�n,ia.t_ <br /> It�-,j f <br /> Signed i - •----•------ --- --------- ------- -------- Owner , <br /> I i <br /> By ......`=. f x s�i �' Title .�.4W-,!!-44'��-- /•' k f! <br /> ------. <br /> (If other than owner) <br /> , <br /> f• 1 fFOR DEPARTMENT USE ONLY <br /> APPLICATION AC�EPTED BY------ ---------------- -- -----•--------•------------..__._-- DATE ---- fr-/..d..:^.7r�-------•------ <br /> BUILDING PERMIT ISSCIED -------------- <br /> - `" -----`-------- -""-- '" -- -'-�' <br /> --------- ---------- -------------------------------- = ...DATE ...........- ------ ..._........... - <br /> ADDITIONAL CbMMEN•TS— "`- - _ _..M_.._ _...� --- ---------- <br /> ADDITIONAL <br /> -------•-.... ........................ -4� ------------------------------------ --------------------------------------------- ------------------------ ------------------ i <br /> I <br /> -•--------------------- ----------- -----------------------------------------------------------.---- --------..-------.--------------------------------------------..........--•---. -• --•------ <br /> -------------------------------------------- • --------- -_ -- ----- ---.......----- <br /> -- --- ------ -.----Date ..... .......-Final Inspection by ---- ---- ............................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> __._-...-E.,-H: 9--- 1•'68 Rev:5M- <br />