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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� � �,y <br /> --------------------------------------------------------- Permit No: ------- -------- <br /> --- <br /> (Complete in Triplicate) <br /> ------ t <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San J aquEn Local Health District for a permit to construct and install the work herein <br /> described. This applicatio ,is e i mpli ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI '---- ?sS. .u____iG �o -- --/�1011 --/-.-----CENSUS TRACT -------------------------- <br /> Owner's Name ------ ------ /�' r ne ----------------------------------- <br /> Address 1 � �''4 - - City � 'yly.......... <br /> Contractor's Name ------------ --- -- -------------------------- ----------------------------=--------License # -------d-.------- ------- Phone ------------------------------ <br /> Installation will serve: Residence '�tment House❑ Commercial ❑Trailer'Court !❑ <br /> ' Motel ❑ Other ________________ <br /> Number of living units_____________ Number of bedrooms _____Garbage Grinder ----------1. Lot Size ________----__-__-__________-___________ <br /> Water Supply: Public System and name ----------- - ---------------- - --------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat[ Sandy Loam •❑ Clay Loam ❑ <br /> �...� Hardpan ❑ Adobe.-E] Fill Material :.`-#-_--=If yes, type ------'---T-------------- <br /> s <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 optic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT �-< SEPTIC TANK;( ] Size__-___:_. _.__--l--r--Liquid Depth _____ <br /> Ca -�+ <br /> acit ` ! , + f <br /> Capacity --I�-�$-`-�TYpe -c- �_ Material----°�A-----!----- No,.�,Compartments ---�-------_--- <br /> Distance to nearest: Well ____ ---_--__Foundation __/_----------------- Prop. Line <br /> LEACHING LINE [ ] No. of Lines ------- ---__-_____ Length of each line------- T.btal Length 16_OA4-.0__. <br /> yp y____� _Depth Filter aterial ____ _ <br /> 'D' Box ____.____._ T e Filter Material�_��� __ __9............................ <br /> Distance to nearest: WellFoundation . ,-_____ Property Line <br /> SEEPAGE PIT Depth- -----I- Diameter Number ----------------- -------- Rock Filled Yes No <br /> Water Table beptY------- = "= =~` ------Rock.Size ---i-----------------•- <br /> Distance to nearest: Well ---------------------------------------=Foubdation°--------_----------. Prop. Line ...................... <br /> r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________ --------- -------- <br /> f <br /> r <br /> Septic Tank (Specify Requirements) --------i --------------------------------------------------------------J <br /> Disposal Field (Specify-_Requirements)' }.« Y '�� j = <br /> - <br /> ____________ ____4_________._______ - <br /> (Draw existing and required addition on reverse side) <br /> 7 _z,. -_ _ _ ter,-„,,�.._ _ ., .- .. �_ �,..._-. - -+ �.--� -�-. _ <br /> I hereby certify that I have prepared this application and that 'the work will be done in accordance wtih 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 signature certifies the following: <br /> "I certify t in t performance ofjhe work for which this permit is issued, I shall not employ any person in such manner <br /> as t bec s ct o r an om a ation laws of California.” ` <br /> Signed ----- :M= ;..O Owner �-� <br /> BY ------------- ------------------------ -------------------------------------------- <br /> -- Title `'-- - ` I <br /> (If other than owner} <br /> - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> - ------------------- --------------'----------------. DATE ---�.'--�- - ---------------------------.� <br /> BUILDING PERMIT ISSUED ---------- e - DATE -------------------------- - - <br /> --•--------- <br /> ADDITIONAL COMMENTS ___________________________ <br /> I <br /> _._________.._______________________________ ___________________________________________-.._______________-_____________!___________________-__________-_______________-_______-_____-__----_--- <br /> ; = F a ---� <br /> - <br /> Final Inspection by: ____ _ Date <br /> ------------------------ -=-------------=------------ ---- =--- <br /> -- -------- ----- - -- - <br /> -= --------------------------------------- ------------- ----- ---- - ------------------------- <br /> - <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> E. H.'-9 <--1 °68 Rex. 5M <br />