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FOR OFFICE USE: APPILICATIOR' FOR-SANITATION PERMIT �M <br />: ............. .- Permit No. .7..... . <br /> (Complete in Triplicate) <br /> G� t <br /> :...:.-..._.........:_..- Date Issued <br /> :.................... ............................... This permit Expires 1 Year From Date Issued <br /> made to the San Joa uin L cal Health District for a permit_to construct and install the work herein 'i <br /> Application is hereby q <br /> described. This application is omplionce with-County Ordinance No. 549 and existing Rules and Regulations: <br /> a <br /> ✓g <br /> _h...CENSUS TRACT <br /> rN ...yJOB ADDRESS/LOr --.Phone <br /> Owners Name' .. T <br /> Address ��. . .f ..ti//f'd der------•--•-- . •--•--• city ......:...................................... <br /> --....-_..._ ., . <br /> ,iContractor's Name ------.__... .....................................................Licen .,Phone ............. ......... <br /> ��"e"#,7 . .. .. ,Pho <br /> ':Installation wiII-terve: Residence E] Ap tment House❑ Commercial {]Trailer Court C] <br /> l . <br /> MotelOther ...44a.-1 = . .72v/ff <br /> Q c d' <br /> � ..... <br /> Number of living units:.....-_... Number of bedrooms _......__Garbage Grinder .___.__-__.- lot Size ............. <br /> 4 1 <br /> 1Nafier Supply: Public System and name .......__g,-1 r1 ------------- -------- .................. •........Private <br /> Peat Sand Loam Clay Loam Iv <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ❑ Y ❑ y ❑ <br /> Hardpan4 ❑ Adobe.�FIII Material.--.::'.=____- If.,es,type�. Y e <br /> �.P <br /> (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.} . <br /> NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTI TANK Size.----•...-.....................-...........=---- Liquid Depth _--_---_--------- <br /> Capacity -- --- Typed= �'• Material . No. Compartments ................. <br /> �- --------- Prop. Line .... - - <br /> Distance to, nearest: Well Foundation <br /> .. _ <br /> LEACHING LINE No. of Lines __.____ :: __.._._ Lengt of a ch fine`.__. Total Length <br /> t j <br /> t 'D' Box ......1---- TYpe Filter Maters C Depth filter oterial T.....-•....•....... ....... <br /> I <br /> Foundation r-_.. Property Line ._ -._ <br /> Distance to nearest: Well .___ -.�_ ___. du <br /> SEEPAGE PIT [ } Depth ................_.__ Diameter ------..-_---- Number ........ ........ Rock Rock Filled Yes [3 No [J <br /> iWater Table Depth -----------•............... ....................Rock Size ............... ----------- <br /> Distance <br /> ---- - x <br /> Distance to neo-rest: Well ----------------------------------------Foundation _....-_- ------- Prop. Line ....... <br /> REPAIR/ADDITION(Prev. Sanitation PerrrtitDate <br /> ...•- r ••-•••----•---.....-••=•.............•---................_...... ......... ........ <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) <br /> ................•I--•-----•_•-----....------•--------•--•---_••------•-------•-•--•-•-•-•-••-------- <br /> --------------]. ......................I.i_..________._ . <br /> �_- <br /> _. .--_ ________________________________________________________________-_---___.__..-----__ .__......._..............____...... <br /> (Draw existing and required addition on reverse side) <br /> ._... <br /> I hereby;certify that I have prepared this application and that the work will be done in accordance with Son 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: =' <br /> l "I certify.that in the performance of the work for which this permit is issued, I shall not employ any person such manner <br /> in su <br /> as to become sub' ct o Workan's Compensation laws of California." <br /> - Owner <br /> F Signed---1`..- Q <br /> Title - <br /> (if other than owner) <br /> s. FOR DEPARTMENT. USE ONLY <br /> BUILDINGON ACCEPTED BY ..- DATE .. -7�-•....:......... <br /> APPLICATION <br /> ------------••------- <br /> ADDITION PERM IT'ISSUkD DATE <br /> ............................................. <br /> ALCOMMENTS ....-•............................................................_----- --------------------------------------------------•------ •---•-- ......... <br /> ------•----• ---------------------------------------------------------•-•-••• •-----..-.. ......------------- <br /> ----------- ••-•-•• .............. ........ <br /> }} <br /> i •................I...... ..----.....-- ..._•.--- .--.------...----•--.....•--•..__....._..••••._......--••.................•• Date _....f. .. <br /> w._ Final inspection by: ......._. � � <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT .._: <br /> ' ,772 3 M <br />