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FOR OFFICE USE: APPLICATION FOR 'SANITATION PERMIT <br /> sa <br /> ---------------- ------------------ <br /> (Complete in Triplicate) rmit No. <br /> ---------- -- ------ ----- <br /> -------------------------:- a <br /> ------------------I-------------------------:------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health" District for a permit to cons uct and install the work herein <br /> described. This applicaJ41on 14Smad ' I' nce w C Ordinance t4o. 549 d Rkiles,an.d Regulations. <br /> e �i co pig _kb QU <br /> A 47, <br /> a/--------------_CENSUS TRACT -------------------------- <br /> JOB 'ADDRESS/LOCAIION _11% - --------X, <br /> t , Phone-4/66 _627�------ <br /> Owner's Name ---- -----------------I- --------- ----------- <br /> -- ----- -- ------- ---- -- 1- - - -- ---- -- ------------------- <br /> Address ----------------- ------- city ----------- ----- ------ ------- ---------------------------------------- <br /> Contractor's Name ------- ---- --- ----- ----------------------License # ------ Phone -W-4779"7---- <br /> Installation will serve. Residence Y0pla, Snet House�E] Commercial 'ElTrailer Court :0 <br /> Motel M Oth r------------ <br /> ------------------------------- <br /> Number of living units:---- Number of bedrooms ---- ---Garbage Grinder ------------ Lot Size ----- ---------- <br /> Water Supply: Public System and name -------I--------------------- I----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand,' <br /> El Silt F C16y E] Peat E] Sandy Loam C] Clay,Loam 0 <br /> Hardpan Adobe ,�K Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit, permitted if public sewer available within 200 feet,) <br /> ... <br /> —or. sewers - <br /> PACKAGE TREATMENT SEPTIC TANK, I Size________,----------< --------- Liquid Depth ------5-Y. ........ <br /> Ty 1444----- Materia I <br /> Capacity pe No. Compartments ----------------- <br /> Distance to nearest: Well -------- Sd--------------------Foundation _____1.9-__________------------ Prop. Line ----/�........ ...... <br /> LEACHING LINE No. of Lines ------- -------- LeKg-fl'i of each line------ ------------ Total Length ------ <br /> 1 le <br /> i. 'D' Box ----- Type+�lber,Material'�—-------Depth Filter Material ---AF:---------------------4W <br /> — -------- <br /> U of <br /> ------------------- Foundation -------le,0---------- Property Line ---Z-0-........... <br /> Distance to nearest: We I <br /> SEEPAGE PIT Depth --- -------- Diameter. _.______- ---- ---. <br /> Number ------- ------------- Rock Filled Yes ' No (C3] <br /> L­41,/V--'4 ;?/L& <br /> Water Table Depth --------- - --------------------------------Rock Size le.7-----------0--------------- Of <br /> Distance to nearest: --------------_---Foundation [[----1------------ Prop. Line ..../_0----------- <br /> Lit <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------- Dcite ---------------------------------- <br /> _#------------------------------------- <br /> Septic Tank (Specify Requirements) <br /> ------------------------------------------------------------------------------- ---------------------- -----.._ ------ <br /> DisposalField (Specify Requiremehts) ----------------------------------------------------------------------- --- ------------------------------------------------------- <br /> -------------------------------------------------------------I-----------------------------------V�---------------------------------------- -------------------------------------I------------------------ <br /> ------------------------------------------ --------------------i------------------------------------I-A-------------------- - ----------------------------------------- ------------------- <br /> (Draw existing and required addition on reverie side) - <br /> Fhereby 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.,ond,Regul.ations a f.the-San Joaquin LocallHealth District. Home owner or licen- <br /> sed agents signature certifies the following: I--I <br /> "I certify that in the performance of the work for which this permit is s issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------- dwner <br /> By ------------- Title -------i ... --------------------------------------------- <br /> (if other 1112 owner) <br /> 'FOR DEPARTMENT USE ONLY rf <br /> APPLICATION ACCEPTED BY -- ---- - - - -- - - - ------------------------------ ---------------------------- ------- DATE --------------- <br /> BUILDING PERMIT ISSUED ---- <br /> ---------------------------------------------------------------- ---------------------------F--------DATE ------------------------------------------ <br /> ADDITIONAL <br /> ---I------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------- --- ------- ,----------- ---------:-;------------- - - . __ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - - -- <br /> ----------------------------------------------------------------------------------- -------------------------------- - ------------------ ----------------------------------------------- ---------- <br /> ------------------------------------ -- - ----- --------- - A 1 <br /> ....0----------- ----------------- <br /> 4 ,F ----------- <br /> Final Inspection by: ---- --------------------------------- <br /> ----- ------------------------ ---- Date ------------ --- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />