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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT T crC� 7 <br /> ------------------------------------- a <br /> -- ---------- Permit - -----•---� <br /> (Complete in Triplicate) <br /> ----------------------------------------------- -------- / <br /> Date Issued �7--.7-=-Vr <br /> ---------------- This Permit Expires 1 Year From Date Issued <br /> ----------------------------------------- <br /> Application q N . it t and existing Rules and <br /> ;s hereby made to the San Joaquin Local Health Distract fora permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance o g Regulations: <br /> JOB ADDRESS/LOCATION ��f -- --- -CENSUS TRACT S <br /> Owner's Name � -- ---------------Phone ---- ; <br /> Address -- -.� ,----674 <br /> � - -�� --�`-'-�--�-- --- - ---------- --- ---- -----------------. city -------------- - -------- -----------------�L------•----------------- <br /> �� <br /> Contractor's Name .--_ - --- -- iter Court <br /> ---- --- --- <br /> License # �- ---- - Phone ---_. <br /> Installation will serve: Residence 4/Apartment House❑ Commercial.❑Tra [] d <br /> Motel El Other --------------------------- - <br /> Number of living units:---- Number of bedrooms -__5_--.Garbo e Grinder ------ Lot Size -------- '-`-- -----• <br /> Water Supply: Public System and name ------------------------------------------------------------ ---------------------- ----- ---------------------Private' <br /> Character of soil to a depth of 3 feet: Sand❑ Silt fl Clay [ Peat❑ Sandy Loam ❑ Cay Loam ❑ <br /> Hardpan ❑ Adobe T-1 Fill Material ------------ If yes, type -----------------------I----- 7� <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 is available within 200 feet,) r <br /> PACKAGE TREATMENT [ I SEP IC TANK Size__ ___X__/0 ________________ Liquid Depth ---- _-.--------.----- <br /> O r <br /> QQ ._ � _ Material-- moo. Com artments _--�-------- <br /> CapacitY � TYPe p �/ <br /> Distance to neo st: Well ----- - -- - ---- - -------------Foundation _. -10--__-------- Prop. Line ---------.... -------- <br /> LEACHING LINE [ No. of Lines -____.-----------Length o each�liine- 4-0- <br /> 'D' <br /> 0- - Total Length �. d <br /> 'D' Bow- ------- Type Filter Material --- --.Depth Filter Material --------I_T---------`--- ------------- <br /> Distance to neare t: Well --------64---- ----- Foundation _.-_ K--- Property Line' - ----- -----------=---- <br /> E SEEPAGE PIT Depth Diameter <br /> Number -------- ------e--e-----t6�-/--�Rock Filled <br /> Yes No .0❑ <br /> 100 <br /> -------------Rock Size ------Water Table De- -rh <br /> Distance to nearest: Well __ QQ_ ------------------------Foundation --- d- Prop. Line _--S ...... <br /> e <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) ------------------ -------- T ----------- =---------------------•---- <br /> Disposal Field (Specify Requirements) ------------- ----------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------- -------------- <br /> ------------- <br /> ------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required 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 San Joaquin Local Health District. Home owner or licen- <br /> sed agents tignature certifies the fallowing: <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 /> ­"&'to become subject to Workm ompensati.o laws of California." <br /> Signed --------------- .. .... <br /> Owner <br /> -------------- --------- Title��'?�.._D/ M_fi_ —-- ----- ----------------------------- <br /> -� <br /> (If other than wnerJ <br /> f, .. FOR DEPARTMENT USE ONLY <br /> APPLICATION,ACCEPTED BY --------------------------- --------------- <br /> DATE _.-�--�-------------------------------- <br /> BUILDING ISSUED :----------------------- ----------------------- <br /> ---------------------------------------------=-------------DATE - -------------,-----------------•--------- <br /> ADDITIONAL. COMMENTS--- -- --:-------------- ---------------------------=- ----------------------- <br /> -: - 'r ! -------------------------------------------------------------- --------- <br /> --------------------------------------------------------------------------------------------------------------- <br /> ------ <br /> -------------- --Ifs:_------------------- - ------ -- -- ------.--------+-- --'------- <br /> Final Inspecfion`bY, --------------------------------------------------- Dae ---------- ---------- <br /> -'? - -- - -- -- - <br /> 9 .� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> E. H. 9 1-'b8 Rev. 5M <br />