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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / <br /> ' Permit No-4�- <br /> r� _f '' �- (Complete in Triplicate) <br /> t. �• <br /> Date issued <br /> ----------------- � <br /> This Permit Expires 1 Year From Date Issued <br /> e work <br /> Application is hereby made lto the ean compl+ianocwial t�h Cou:tyealth tort inane permit <br /> d existing Rules tand hRegulationsrein <br /> described. This application <br /> ------------- CENSUS TRACT <br /> JOB ADDRESS/LOC TION . - <br /> - e , <br /> _ Phone <br /> G J <br /> Owner's Name ._ -=fflr � <br /> ------ --------------------------------- <br /> --�� ' A - ---- -------------------- city _ - - -------------------------'"--•• - -- <br /> Address ____--___ • //V1� <br /> � -.License # �_?_.3 Phone V6-,=N <br /> Contractor's Name ____ <br /> Installation will serve: Residence�j(Apartment House,M Commercial:[]Trailer Court :❑ <br /> Motel ❑Other --------------- - -h ` <br /> G ba a Gr' der Lot Sizezk l`J� <br /> Number of living units------ __ Number of drooms _ ------ g <br /> ------ -- <br /> Priya <br /> ' Water Supply: Public System and name # r <br /> Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loo ❑ <br /> Hardpan ElAdobe Fill Material ------------ If yes,type ----------------- <br /> + buildings, etc. must be pla'ed on reverse side.] <br /> (Plot plan, showing size of lot, location of.system in relatio to wells, <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 4 <br /> f <br /> PACKAGE TREATMENT [ Size-- Liqu+d Depth ________------------------ <br /> --------------- . S <br /> SEPTIC TANK' F � - - iNo Com c rtments <br /> Material__�. fru--- P <br /> Capacity I _� -- TYPe �6 w _ t _.�- -�._, <br /> Distance to nearest: Well ______ <br /> Foundation -- --------- Prop. Line <br /> LEACHING LINE No. of Lines _ �"----------- Length of each line-757Y Total Length"'------�---- <br /> 'D' Box ----/----- Type Filter Material S! -Depth Filter Material _____ ^ <br /> ------------- <br /> Distance to nearest-. Well - � Property Ln <br /> p <br /> Diameter - - ------- Number ----"---- --- <br /> ."""________ Rock Filled3Yes No <br /> SEEPAGE PIT ..Depth _ - -------- ` .� •T. " ) <br /> Rock Size " , <br /> Water Table Depth ------- --------------- - �` ! -------- <br /> Distance to nearest: Well ___ ____ _____ ________""---- <br /> ------Foundation ---- ---- -- Prop. Line <br /> ) <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ---------------------- -------`-- <br /> � <br /> Septic Tank (Specify Requirements) "."----------------- -------------------------------------•-------- <br /> Disposal Field (Specify Requirements) -"-.---------- ------------------------------""-""""""---" <br /> = <br /> ``` --------- <br /> r <br /> A -------------------------- <br /> ---------------------------------------------------- <br /> -------I------------ <br /> -------- ---- -- - - - - - ------------- --- i <br /> {Draw existing and required addition on reverse si d e] <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. Homeowner or licen- <br /> sed agents signature certifies the following: <br /> if that in the erformance of work for which this permit is issued, I shall not employ"any peso'zin such manner <br /> "I certify p <br /> as to be su ]ect to Wo an' mpensati. n s of California." <br /> Owner <br /> iSigned ---- - -- -- - ---------- --- - � <br /> --- -`----------- Title --------------- - ------------ <br /> - - ------------------------- <br /> (If other tha owner) <br /> FOR DEPARTMENT UISE ONLY <br /> APPLICATION ACCEPTED BY -- -- ----- --------- -- --------------------------------------- DATE ,---------------------- ---------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------------- -------------------------------------------------------------DATE ------------- --,------------------- ------ <br /> ADDITIONAL COMMENTS ----------------- ---------------------------------------------------------- - <br /> y -------- <br /> ------------------------------------------------------------- <br /> ------------------ <br /> '------------ ---------- -----------------------------------------------------------------------------------------------;------- <br /> --------------------------------------------------------------- -- <br /> ---------Date-9. <br /> ---------------------- <br /> ------------- <br /> Final.lnspection by: - _ <br /> ;., SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> H. 9 1-'68 Rev. 5M <br />