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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT �� _� f <br /> � Permit No. ............... .. <br /> .............................................. <br /> (Complete in Triplicate) <br /> ............................. . p Date issued .�:.�--•7;3 <br />.....--.I.,.............. 'T <br /> . <br /> This Permit Expires 1 Year From pate Issued <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. Sp9l and existing Rules and Regulations: <br /> ,� ?... ......................CENSUS TRACT ......... <br /> JOB ADDRESS/LOCATION ..... ._. P ,+ <br /> ..Rl..v �.._... ..!_.�.��- ... , •---......... ----- have .....C�... .a. � . <br /> Owner's Name ._....13n <br /> Address ._. :..�...City .., ,,� - i. - T. <br /> � ..... <br /> . -.License # . '�•�._ -- Phone . . <br /> Contractor's NI serve D Residence C3 Apartment Mouse Commercial ❑Troller C ' r <br /> ourt, <br /> Installation Will <br /> Motel [3 Other ..............................:............. <br /> Number of living units:__...- Number of bedroom.,_ ... .•.Garbage Grinder ............ Lot Size -------­----- <br /> Private <br /> Water Supply: Public System and name ......................:•;............. <br /> .. - ._....... <br /> Character of soil to a depth of 3 fest: Sand❑ .. Silt❑� Clay C] pool^❑ Sandy Loam 0 Clay Loam 1Z <br /> Hardpan ❑ Adobe .Cj Fill Material ............ If yes,type --------_-----• -­--_ <br /> z, <br /> (Plot plan, showing size of lot, I tion of. systemin rel on to wells, <br /> buildings, etc. must be placed on reverse side.) <br /> 11 r} <br /> NEW INSTALLATION: (No tic tank or seepage spit permitted if public sewer is available within 200 feet,) <br /> �,,�'' ze.... . Liquid Depth .......................... <br /> PACKAGE TREATMENT SEPTIC TANK ] .... ...---•--.... <br /> �Q Material............... ...... No. Compartments ...:. ........� <br /> Capacity - --- Tyke p Li i <br /> :..Foundatio Prop. Line ..... ....!f_ •- S <br /> Distance to nearest: Well .__ �_ ..----- <br /> . ••........ <br /> i <br /> . Length of ea line............. _ -. ..__.. Total Length ....±_...�.a.•.•-.._... <br /> LEACHING LINE No. of Lines ..........y........ g <br /> ...De Depth Filter Material -------..�.... ................ <br /> `D' Box ............ Type Filter Material ...�:.. P <br /> Foundation Property Line .....�•--••-....... <br /> Distance to nearest: Well ...... - ••---•••-•- � - <br /> SEEPAGE PIT [ ) Depth ..._ Diameter ... .... ---•-•_. �" <br /> r .h <br /> Wate6Table,Depth _-- . ...... ock Size ....•---- •- .... <br /> ,> <br /> t r .. _' Prop. Line <br /> Distance to nearestWe jl..�'__ -----.-••• <br /> Foundation ... o <br /> REPAIR/ADDITION(Prev. Sanitation Permit d� =- •'•'-•--------•----- <br /> ........ Date ..................................} o <br /> ' <br /> Septic Tank (Specify Requirements) .............f._.__................... <br /> 1 d <br /> Disposal Field (Specify Requirements) ------ ........................................................----------------------- <br /> r <br /> (Draw existing and required addition on reverse si e <br /> F 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 or licen- <br /> sed agents signature certifies the following: arson in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any p <br /> as to become su cwp Wo r n's Compensation laws of California." <br /> Signed ........... <br /> ............................ <br /> ...................................... <br /> Owner <br /> ................ Title ..._�r....._......_..._..,.._...._..... <br /> By ................. ....----.._.......--... .. <br /> (If other than ownnerer)) <br /> FOR DEPARTMENT USE ONLY <br /> ........:.................. DATE.. <br /> APPLICATION ACCEPTED BY ... ..................................... <br /> • <br /> DATE _.... <br /> BUILDING PERMIT ISSUED .......... . ..... ... ...:.................... .......... <br /> ADDITIONALCOMMENTS ........................................ .........._................._..........._......__...... <br /> .---------..._.................•--.....--- •-• ....... ...... ----••-----•-•••--•...... ........ ---••- <br /> :.... _ .................•-......... --.-• <br /> ................................. ............ --........... <br /> 3/rz,/7 _.._..... . ...........................Date . <br /> - Final inspection by: ...................................... . <br /> a &° '1 -6r CGrC4VUG kA r JO UIN LOCAL HEALTH DISTRICT <br /> 7/723M <br /> '� z Lj 13 24 i.,Ae !te <br />