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' -FOR OFFICE USE: <br /> .APPLICATION FOR SANITATION PERMIT <br /> /O3 <br /> ----- --------------------M--------- - ---------- ____ ;t,� Permit No: <br /> (Complete in Triplicatel -" <br /> ----------=----------------------------------------------- <br /> k - -- ----------------------------------------_____ This Permit Expires 1 Year From Date Issued <br /> Date Issued 44:7&10 <br /> i Application is hereby made to the San Joaquin Local Health,District for a permit to construct and install the work herein <br /> described. This application .is made in compliance 'with Cdunfy Ordinance, <br /> No. 549 and existing Rules and Regulations. <br /> �HSC--�.{A� ,._.. � .-wrv.•.�-.��......� ..�...---..- .w__,_. <br /> JOB ADDRESS/LOCATION ._-_ --,C6---__ -. - ------_--- M/�✓® U� <br /> ----- -------- ---. CENSUS TRACT ----�-Z--- <br /> Owner's Name ----- y ._- - _ -PhoneY , . --/ <br /> Address ------------- da ------<_ y------• City --------------------- ------------- l ----------=--- <br /> -------- ------ <br /> Contractor's Name --- <br /> ------ License # ' Phone ' <br /> -------•-•- <br /> Installation will serve- Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ---------------------------•---------------- <br /> t <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------- Lot Size --_--________________YY_____--______________ <br /> Water Supply: Public5ystem and name ---------------------------------Private ❑ <br /> Character of soil to a`depth of 3 feet: Sand❑ Silt❑ Clay .❑-• Peat❑ Sandy-Loam--❑- ''Clay'Lozrm <br /> I <br /> `'• Hardpan ❑ Adobe'❑ Fill Material_'­_--1f-yes;type __- _----- »- <br /> ----------- <br /> (Pl'ot plan, showing size of lot location of system in relation to wells, <br /> P 9 y buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer,is availa'ble within feet,) <br /> / �� .T { 7 SEPTIC TANK [ ] Size �------ '---- Liquid Depth ---------------- ----- <br /> PACKAGE TREATMENT <br /> I` �� Capacity -------------------- Type ----------- ------- Material-------------.------ No. Compartments 4.-----------------. <br /> �.� Distance to nearest: Well -----------------------------=------Foundation ------- '--= i -Prop. Line #_--------.---_----••-- <br /> LEACHING LINE ¢� ; No, of Lines ------/--------------- Length of each lin `fi _._?`-_____."- Total Length`-._—!– <br /> �S7�N D' Box x Type Filter Material. � th Filter Material ___ � � .- <br /> _ --------- <br /> - <br /> Distance to,neargst: WVII _______ Foundation ...j_0------------- Property Line. ________________ <br /> SEEPAGE PIT [�] ' Depth iameter ........ <br /> _____.t_--_____ Number ____________________________Rock.Filled Yes ❑ No i❑ <br /> S1lMP i Water Table Depth -------------------------°----------------------Rock Size ---------------- ------ -------- <br /> Distance to nearest: Well .__/ __t ___ _____________Foundation ��--' Prop. Line __ <br /> ----_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -.------------------------------------------ <br /> - Date ---------------- -------'---t------- <br /> Septic <br /> -- <br /> - <br /> Se tic Tank (Specify Requirements) ---------- <) <br /> .: ----------- ----------------------------- <br /> Disposal Field-(Specify Require � M� --_--- --_ -- � T , <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 signature certifies the following: <br /> "I certify thtin he performance the ork r ich this permit is issued, I shall not employ any person in'such manner <br /> as to beco a ject to Wo m p t of California." <br /> Signed _ Own— r <br /> - <br /> �, r i <br /> BY ---- ------------ ------ ---:-------------------------------------- --------------- ` Title �- <br /> If of br than owner) <br /> FO EPA-IltTMENT USE ONLY r € <br /> APPLICATION ACCEPTED BY -------- ----- ----- ------------ ------------------ w----------- -. DATE -_./:�= �f <br /> BUILDING PERMIT ISSUED ------------------------------------------------------ _-'DATE. -------------------- <br /> ALCOMMENTS -- -- -===---_---------- ---------------------------•- •--- ----------------------- - --------(--------------"'"."_.."�.----�,�----------'---------- <br /> ---------- ----- ----------------------------------------------- ` " <br /> w <br /> -------------------------------------------------------------------- <br /> -------------- --- --- ... <br /> --'-------------------------'---------------------------- -- �-- <br /> �. <br /> -------- - ---- -- _---- -----------------=' ------ <br /> Final Inspection by: ------- •.-" �.__ ---------- - - --- <br /> ���------------ <br /> SAN AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />