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Permit,No _ <br />Date issued .S.:7Zq."2.4 <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Triplicate) . P. • "t.". <br />This Permit Expires 1 Year From lisut <br />Application Is hereby made to the San Joaquin Lam! Health District for a permit to construct and install the work herein <br />described. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulations; , <br />JOB ADDRESS/LiciCA ‘L TI <br />-et <br />, 2-4242) ,,.XS — e • <br /> <br />- <br />CL-------ir-r.4, • CENSUS TRACT <br />I <br />Owner's Norne ,,, Phone <br />Address . ...... i.,!+.3 .i) City 1 /4. <br />Contractor's Name .. License # i <br />Installation will serve: , Resi tote . Houser] Commercial °Trailer Court 0 \ <br />Motel 0 Other • , , ., I. <br />Number of living 'units: 1 S 'Number of , bedrooms ' ›.--- Garbage Grinder ' Lot Size <br />Water Supply: Public System and name " • ' . Private 4 <br />Character of soil to a depth of 3 feet: Sand 0 L Sift 6, Clay EL Peat 0 Satx Loam 0 Clay Loam 0 ,. _ _ <br />' S Hardpaff riy" Adobiltj — Fill Material ..._ .... .. if yes, type <br /> —.................— <br />(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side) <br />NEW INSTAUATION: (No septic tank Of seepage pit permitted if public sewer is available within 200 feet,) <br />,I <br />PACKAGE TREATMENT ( ) SEPTIC TANK { ) •— i 4 Size. Liquid Depth <br />Capacity ' Type 2.- Materkt1 No. Compartrnertts ..... ...... _ ... ....- <br />.. Distance to nearest: Well Foundation Prop. Line <br />'EACHING LINE r ] Ni. of lines , .—i • Length of each II T . Total Length, I ' <br />'0% Box .! ' Type. Fitter Material ' Depth filter Material . <br />DistanCe to nearest: Weil' Foundation Property Line <br />SEEPAGE PIT t 1 Depth • ' ' Diameter ' Number Rock Filled Yes 0 No <br />Water Table Depth Rock Size <br />Distance to nearest: Well Foundation . <br />REPAIR/ADDITION (Prey. Sanitation Permit # Date <br />Septic Tank (Specify Requirements) <br />Disposal Field (Specify Requirements) <br />43. "x <br />• t <br />1 <br />Um .1Dciaw existing and reqUired addition on reverie side) <br />I hereby certify that I have prepard this application (tad that the work will be dons in accordance with San Joaqule <br />County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health. District. Home owner or Ikea: <br />, . <br />red agents signature certifies the follOwing: s <br />"1 certify that in the performance of the work for which this permit is issued, 1 shell <br />at: to become sublect to Workman's Compensation laws of California." ' <br />r . Owner <br />Yitie (7.p—itt-c-4A- <br />, <br />R -DEPART ENT ust ONLY _ <br />ot employ any person in such manner <br />Signed ....... . . .. ........... <br />By: <br /> <br />(If other than owner) - <br />APPLICATION ACCEPTED BY, <br />BUILDING PERMIT ISSUED <br />kDDITIONAL COMMENTS <br />DATE <br />... .,••••1 <br />• ••• • • ••••• <br /> <br />Da <br /> <br />Final Inspection by: <br /> <br />8/714 3M <br /> <br />EH 13 214 1-613 Rev. 94 N JOAQUIN LOCAL HEALTH DISTRICT <br />