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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: -7 z- - 0 <br /> -- --------- i <br /> - ---------- <br /> --- -------- (Complete in Triplicate) <br /> 7 - 7 t� <br /> ------ - Date Issued -----=--- --- --- -- <br /> This Permit Expires 1 Year From Date issue <br /> ----------------------------------------------------- <br /> Application is hereby made to the S n Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> .-CENSUS TRACT --------------•----• -___- <br /> JOB ADDRESS/LOCATION --- ----- , Phone._ ---------�------ <br /> .�- <br /> Owner's Name _.------- <br /> TeAlY/ -/ �Y <br /> �+/ _ Cit ------------------------- <br /> Address <br /> - - - <br /> Address ------a'_l--O'�----- �7 G / � - -•�- <br /> ` , f 6 Phone - --•-------- <br /> ___ _ __ _---.License # /�� -:-"----- --- <br /> Contractor's Name O" " <br /> Installation Jill serve: ResidenceX Apartment House❑ Commercial :❑Trailer Court l,❑ <br /> Motel F1 Other -------------------------------------------- •' <br /> ✓ f)c7✓ E.5 __ I <br /> _ ___ Number of bedrooms �---.---Garba�c a Grinder =---_ Lot'Size -l---------------- --- ----------------- -- <br /> Number of living units:___-I_ - ; <br /> -�� Private 9 <br /> --•------ -------------------------- <br /> Water Supply: Public System an name ___________________________ # <br /> Character of foil to a depth of 3 feet: Sand[] Silt❑ CILy ❑ Peat❑ Sandy Loam ®' Clay Loam:❑ �.7 <br /> Hardpan F1 Adobe'❑ <br /> Fill Material ------------ If yes, type ----- ------ <br /> I <br /> Ian showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.} <br /> (plotp �l! <br /> NEW INSTALLATION: (No septic tank or seepage pit permi ed if public sewer is available with n 200 feet,) <br /> Site------------------- Ligid Depth <br /> t" <br /> PACKAGE-TREATMENT [ ] <br /> SEPTIC TANK [ 1 <br /> i No. Co t partments <br /> Capacity -------------------- Type --- <br /> Material---- ------ ------ <br /> -,� Distance to nearest: Wel! --------------- - -- - ----------- -Foundation --------------------- .Prop. Line ---•------- <br /> ---- ---__ Length pf each line---- <br /> TotalLength ---------------------------- <br /> LEACHING LINE [ ] No. of Lines <br /> I' _Depth Filter Material _ __ <br /> 'D' Box ----- ------ Type Filter Material -------------- <br /> i Distance to nearest: Well ----------------- == = Foundation �^ ^�- '""`Property <br /> Line. ------------------------ <br /> Depth Diameter Nu ---------------------------- Rock Filled Yes ❑,7 No <br /> i SEEPAGE-Pf [ 1 p e 1- <br /> Water Table Depth---------------------------------- '" }--Rock Size --------•---------------- <br /> ! ----- -•-Foundation -------------------- Prop. Line <br /> Distance == <br /> to nearest:-.Well __"_______,,.____5 �___ <br /> r <br /> -- �- ---- - J � <br /> rt <br /> 'f� <br /> Date ------------------•---••--•------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit -----------------M - <br /> ia--------------------------------------------------- 1� f - '-rSeptic Tank (Specify Requirements) --------------- --------------------------- <br /> Disposal <br /> - •------------ - <br /> Disposal Field (Specify kequirements},; _____ _- ----- <br /> 5-77e,--q <br /> E=X' S 'i'�1''cj 5 -5--�e,�----------------------------------------------------------------------- ---------- - -- <br /> �-�------- <br /> i r <br /> --------------- <br /> (Draw existing and required addition on reverse side) <br /> uin <br /> ne in <br /> ce with <br /> I hereby cert that 1 have prepared this application snd that the work will be of the San Joaquin Local oHealth DistractnHome owner or iiiccen- <br /> County ordinances, State Laws, and Rules and Regulation <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 /> tion laws of California." <br /> as to becomeisubiect to Workman's Compensa <br /> t Signed �.�t- <br /> - <br /> Sbl1� Owner <br /> ' ---- ------------------------------------ <br /> -----------------------------•------------- <br /> -------- -- Title ----- - ----- --------- --- - <br /> �(if othe ner . <br /> FOR DEPARTMENT USE ONLY <br /> DATE ------------------- <br /> APPLICATION' ACCEPTED BY ------- --- =--------------------------------------------------------------- <br /> " -- ---"--------------------------------------------------- ---- -------DATE ------- ---- -------------- --------- ------------------- <br /> BUILDING PERMIT ISSUED ----------------- ------- -------- -------- - <br /> ----------------- ------------------------ <br /> ADDITIONAL�COMMENTS -----------------------------------"------------------------ - <br /> ---------------------------------------------------------------------------- <br /> ----------------------------- ------ ------- ---------- -_ - --- ---------------------;3 - - Z- - - <br /> D - <br /> - ----------------- -- - -- - - - to -- - --- -- <br /> _a <br /> Final Inspection by: ---------------------------------"------------------------------ <br /> -- - --- - -------------------- - <br /> SAN JOAQUIN LOCAL ALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M _ <br />