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FOR OFFICE 115t` APPLICATION ICOR SANITATION PERMIT <br />......................................................... <br /> .. .. Permit No.(Complete in Triplicate) <br /> _ . .. . . _ _. _.. .. .^ <br /> This Permit ! Year From Date Date Issued <br /> ... . .... . .... ............. . _ _ . <br /> (Application is hereby made to the San Joaquin Local Health District for a permit. to constnid and install the work herein <br /> described. This application is made in compliance wO Count Ordinan No. 549 and existing Mules and Regulotionsr <br /> t <br /> ...............: <br /> SOB ADDRESS/LOC�jAfj/ION CENSUS TRACT <br /> .... .....v <br /> Owner's Name sem( pp 4. .. .�... .. .. .......................................................Phone <br /> Address ..If...c-. dam. 'C .........................................City ..r..................... .........._/..�j� S, .Q.......... <br /> Contractor's Name .......47- ------ ........................................................License # ...................................... Phone ... <br /> installation will server Residence Apartment House(] Commercial❑Trailer Court ❑ <br /> Motel❑Other............................................ ' 17(J �~ <br /> Number of living units:............ Number of bedrooms .........---Garbage Grinder ............ Lot Size 2-"4.J0 L. . ..u.. ........ <br /> Water Supply: Public Systam and name ............................._--------------------._---.................................................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat 0 Sandy Loam❑ day Loam ❑ <br /> N, Hardpan❑ r Adobe{Fill Material ............ if yes,type............... ............ <br /> (Piot plan, showing size of lot, location of system In rotation to wells, buildings, etc. must be placed an reverse side.).., <br /> NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ....... -�.... <br /> PACKAGE TREATMENT k.10"'SEPTIC TANK 14-1, y��}} Size...4 X...�..I...Jr...��......... Liquid Depth ,.��... <br /> Capacity . -.L2.�..... Type Ne !art MaterialCx.—CO.Z4. No. Compartments ... :...... <br /> • <br /> Distance to nearest: Well k5k__.....................Foundation ...... Prop. Line `s <br /> LEACHING LINE [ ) No. of-Lines ........................ Length 'of each line......................• ... Total length ............................ <br /> 'D' Box ---.. Type Filter Material ...................'Depth Filter Material .......................................... <br /> 1 �. a . <br /> . , Distance to nearest: Well ........................ Foundation ........................ Property line ....... ......,... <br /> r <br /> � . <br /> EEPAGE PIT [ 1 Depth ........................Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> Water Table Depth ....:...........................................Rock Size ................................ <br /> Distance to nearestr Well ..... . ................................Foundation .................... Prop. Une ..................... <br /> REPAIR/'ADDITION(Prov. Sanitation Permit# ............................................ Date .. ,........ _................. <br /> Septic Tank (Specify Requirements) .................................. ... --.........................................................._............._.................. <br /> DisposalField (Specify Requirementsl ................................... .._ _.................................................. ................................. <br /> ...--•--••.•--•--------•......................................•..--•.....................................................................----•..........................._................................ <br /> (Draw existing and required addition on reverse gide) <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 sr Rcen- <br />` sod agents signature certifies the following: r <br /> "I certify that In the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .. .a2, rk, .... !� .. .. Owner i <br /> By ` .......... title k <br /> (!f other than owner) -17 <br /> F EPARTMFNJ6 USE ONLY ' <br /> APPLICATION ACCEPTED BY ....... DATE <br /> .../ � ....: •--...........: <br /> BUILDING PERMIT' ISSUED �...� . ... D <br /> ..---.......r.... ................. .. <br /> ADDITIONAL COMMENTS . .. ' <br /> ................... ....................................................................................................................................I......... <br /> ....... <br /> ...............................--------.............. ....... ............ <br /> ................................---.....-. . <br /> .--... .- <br /> final Inspection by : .................Date .... "......._ <br /> �' <br /> Ela 13 24 1-68 &v. 5K SAN JOAQUIN t HEALTH DISTRICT $1711 3H <br /> Cc.� <br />