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FOR OFFICE U�. <br /> _ 3� APP�iLICAVON FOR SANITATION PERMIT / <br /> f.r --- -- Permit No.C��'__--- <br /> - {Complete in Triplicate} �.�?- <br /> ---------------------------------------------- <br /> This Permit Expires 14Year From Date Issued Date Issued _���------rrPf <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 .----- - -- - ---<f--- --- ---------- ------------------------CENSUS TRACT --------- <br /> Owner's Name � �rt.�y - ------Phone <br /> --------------------- a� <br /> Address '�1+� 's,-- � City <br /> - ----- -----•------- ---------------------------------- <br /> r� <br /> Contractor's]Name ' ' '+�.,r4co, ---------.License-#f�+Q, ��--------- Phone <br /> Installation will serge.` Residence Apartment House❑ Commercial Trailer Court ;❑ <br /> } Mote Other -------------------------------------------- <br /> Number of living units:___.1_____ Number of bedrooms __0- Garbage Grinder ._________ Lot Size __S_O_. t"------------------- <br /> i - <br /> Water Supply: Public System and name -------------------------------•-•-----------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam •0 Clay Loam;❑ <br /> Hardpan ❑ Adobe X Fill Material ------------ If yes,type ________________-______ <br /> X W . <br /> (Plot plan, 'showing �ize of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: 4p(Noseptic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMESEPTIC TANK Sizre <br /> ---------------- - - ------ Liquid Depth ------------ 1L4 <br /> Capacity --------- •P -------------- i--- Material--------------- ------ No. Compartments ------•--------------• 7 <br /> P Y -- Type i � . <br /> Distance to nearest' <br /> earest ------------J-------------------Foundatio''n ---------------------- Prop. Line ---------------------- <br /> LEACHING <br /> --------- ----- _.LEACHING EINE f ] No.. of Lines -iW611 <br /> ..- -L g ------------ Total Length ,----------•---------------- <br /> _ ____._ _ ren Length of each line-_ _ _. _ <br /> .� D,� Box-� ..___-._ Type Filter Material ------------------Depth:,,Fil er Material -------------------------------------•------ <br /> Di ta'n ,to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------•------:---- <br /> t <br /> SEEPAGE PIT { ] Depth _.___�._.________ Diameter __________-___ Number----------------14 Rock Filled Yes '❑ No i❑ <br /> # Rock <br /> Water Table' Depth ----------------- -- nSize -------- ----------------------- <br /> Distance tolnearest: Well��--------------- ------ -----------------Foundation -------------------- Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------4_"1___________ ______ __ __ Date _-___________.___________________) <br /> Septic Tank (Specify Requirements) __---_-------_- _ r <br /> -- --- -- -- - <br /> DisPosal Field (Specify Requirements)1 ---------'�- -�- Lrf <br /> � --------- + <br /> -------------------------------------------------------- --------------- <br /> - Y �� - <br /> ----------- --------------------------------------- ---g_,------------- ----- - -- <br /> - - - - - - - ------------------------------------------------------------------- <br /> -(-Draw-existin and-re uired addition on reverse side) <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 ofthe San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: ll <br /> "1 certify that in the performance of the work for which this permit is issued, Ishall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- ----------- -y--------------------- ----- ----- Owner <br /> BY - -- ------ Title --- ---- !-- <br /> ----------------- <br /> -------------------- <br /> other than owner)`� <br /> Jj )^ ',O' R'`DEPARTM'ENT: USE ONLY <br /> APPLICATION ACCEPTED BY ...1___eAJ-><` __0_r - - - --------- -------- ------ ------------------------------ DATE ---- ,�) ° ----------- <br /> BUILDINGPERMIT ISSUED -------- ----------- --- ---------- ------------------------------------------------------ --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------- --------------- --------------- ------ ----`------= ------------- ------ <br /> ------------------------------------------- <br /> -------- ------------------------------------------------------------------------ --------------------------------------------------- <br /> -- --------------------- <br /> Final Inspection by: -7 ------- --- - Date --- -- -� <br /> ------ -- -- <br /> SAN" JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />