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FOR OFFICE-USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> .--•-----------=----•......_•.:...-------•-....... Permit No. <br /> Wbinpleto In Trlpllco6) .... ............... <br /> ........... .... Dote Iss4, <br /> /eueThis Pemi4t Ex0ireslYear From Date Issued 7 <br /> Application is hereby made to the Son Joaquin Local Health District' for a permit to construct and Install the work herein <br /> described. This application isc ^I un <br /> a am 111on Ith e County Ordinance No. 549 and existing Rules and Regulations: <br /> Ue� <br /> JOB ADDRESS LOCATION & C...............................................CENSUS TRACT ................ <br /> Owner's Name .. .. ...4"W1 .., 2 .. ................................Phone -0--__-_. <br /> ---- ................................... city ...................­­.—.................................. <br /> Contractor's Nome <br /> . ............................. ........License # ..........­........... Phone .............. ............ <br /> Installation will serve: Residence XApartment House] Commercial OTraller Couit <br /> Motel []Other................ .............. ............ <br /> Number of living units:_/------ Number of.bedroomsA�4..GAage"Grinder ......... Lot Size ...... <br /> Water Supply. Public Syitem and name ..............L...... ............................... <br /> I _­...................._...... .................Private. 0. <br /> Character of soil to a depth of 3 feet: Sand[ S Peat any Loam 0 Cay Loam <br /> 0. Ilt E] - Clay A PtSdLl0 " <br /> Hardpan Adobe 0 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 alcle.) I <br /> NEW INSTALLATION: (No septic tank at see pd,9.e It permitted If public sewer is available within 200 feet, <br /> .................... ................Liquid Depth .................. <br /> PACKAGE TREATMENT I ] SEPTIC TANK <br /> SizeZ <br /> Capacity/,Z90J-^4_.. Type..................... MoteriaI6(!N!WA*_ No. Compartments, ..-;;?n------------- <br /> Distance.to.nearest: Well `_r.Dfd./146IC-/d/.-I/atFoundati6n .../:3 ...... Prop. Line ...................... <br /> LEACHING LINENo. of Lines ............. Length of 'a <br /> p ch line-../040................. Total Length ................ <br /> 'D' Box ...... Type Filter Material <br /> _.......De th Filter Material .47.V................................ <br /> Distance to nearest: Well Aihz-�141/-#Apunclation ------------------ ..... Property Line <br /> S ep <br /> E PIT I Depth ----- Diameter ,_-1.3.__:_-.--3. Num/6er ...../..................... Rock Filled Yes No <br /> Water Table Depthe�`­.... .................. .......... ....Rock Size .."Z_ .... ...... <br /> Distance to nearest: Well'pljjzif--.../ -.;Foundotion ........ Prop. Line ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit . Date ........................... <br /> ............ <br /> Septic Tank {Specify Requirements) .........I........... ........... ............. .............•----•--•-'...---•----••.........__. ........... <br /> Disposal Field (Specify. Requirerrtents) ----------­-----­ <br /> .................... ............... ......... ...... ................ <br /> .. . .......(--------------------- <br /> ---------------------------------- ------- ...... ..... ------ ... .......... ........................... ................. ............... <br /> ------------------------------------------ --------------------­ ---------------------- <br /> ............ ........... ................................... ............................. <br /> '(Draw existing ohd'f6quirecl 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 of the Son Joaquin Local Health,,District. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "I certify that In the performance of the work for which this permit is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------- ---------------------------------------------------- ................ Owner <br /> By ------------ ------------- ---------------------------------------------------- Jitle ------- ......... -------------- <br /> --- - ---- ------- <br /> of other <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By <br /> ........................................... <br /> BUILDING PERMIT ISSUED ................... DATE-11,27-17.)=... ............ <br /> .... ......:...........................DATE ____................................ <br /> ADDITIONAL COMMENTS <br /> ----------------- --- ----- -- - <br /> .......... ------- - ----------- ------------------ .......... <br /> .............. ------------- - ------ - -7" <br /> ..........I..................m......... 011< <br /> -------------------------------------- <br /> ---------------------_--- ... ............ <br /> Final Inspection by: ---114 -------- - ----- ----- -- _----- <br /> -- ----------------- <br /> -- ------- -- <br /> �5� -ZA -— " - ' * '- - -.-t,6 - Date , <br /> RH 13 24 1-68 Rev. SAN JOAQUIN L HEALTH DISTRICT 6/7h 33T'1� <br />