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FOR OFFICE USE: I� APPLICATION FOR SANITATION PERMIT �/ 5 <br /> - t�. -- - Permit No. --7 7 <br /> (Complete in Tripiicate) / <br /> ........... ------------- -- <br /> 7 - ---.---- - Date Issued --------•----------- <br /> This Permit Expires 1 Year From Date Issued <br /> --------------------------------------------------------- <br /> Application is hereby made to the So Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made ` com liancety Ordinance No. 549 and existing Rules and Regulations. <br /> ,. <br /> -------- <br /> CENSUS TRACT --- <br /> - <br /> -----------------•_.JOB ADDRESS/LOCAT - ' Jo-- L ( a--�(A- - <br /> All <br /> Owner's Name ------------ ------------------------------------------------ ------- Phone ---------- = <br /> --°--------------------------- city -- �---------------------Address --- <br /> i <br /> Contractor's Name � ' Phone ------- <br /> _ Licen <br /> se # -� <br /> f <br /> Installation will serve: ResidenceApartment House ] Commercial :[]Trailer Court ',❑ { <br /> l <br /> Motel ❑Other ----------------------------- ------ <br /> Number of living units:- ----- Number off/bedrooms ------Garbage Grinder/s=.;�--- Lot Size _f�{�-,�C__���------------- � <br /> Water Supply: Public System and name -L �� �p3► i --- Y private ❑ <br /> Charocter�of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes, type _______________________-__ <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 se a e it permitted if public sewer is available within 200 feet,) 1. <br /> p g t p p � <br /> _. _. _ ..�. .. . . <br /> PACKAGE TREATMENT [ ] SEPTiC TANK Size__ __ - --------------------- <br /> Capacity, P-Ro------ Type�r l__-- Material __-'--- No. Compartments --- ____..•.----- -- 1� <br /> s <br /> — Distance to nearest: Well __`__-___________----------------Foundation ( _---____---- Prop. Line __���' ---------- <br /> F <br /> __.-- ) <br /> LEACHING LINE No. of Lines --- -__---___..__ Length of each line—g?5��_ ___ .- ---_-- Total Length 1-7f�---------------- <br /> __ Len -- - - - F <br /> D' Box _._ Type"Filter Material - � -Depth' Filter Materialf ------------ ------ -............... <br /> ----------- - <br /> - - _ — Foundation <br /> v"Distance to nearest: -We11-_-�__._,_____ "----�--' Property Line <br />€ SEEPAGE PIT [ ] Depth/A9-------------- Diameter Number ___ - _._----___________--Rock Filled Yes ] No i❑ <br /> -sit' . Water Table Depth g;� ``'RockrSize ��jj <br /> Distance to nearest: Well ----- ------------- Foundation �-:--.--- Prop. Line ...L-___----__.___.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------s- Ddte _--;,---------------------- <br /> -------------------------- <br /> _______--------- ----) <br /> r i <br /> Tank (Specify Requirements) -------------------- ----------------------------- ----------------------------------------- <br /> Septic .� <br /> Disposal Field (Specify ,Requirements) --------------- ---°-----------------------}---------------------•--•---------••- . <br /> ---------------------------------------------- . <br /> { ________________________________F_____________-.--_-_.___--_--________- <br /> ----------------------------------------------- =---= -------------------------------- <br /> (Draw existing and required addition on reverse side) i�. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San .loaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or Hien- <br /> sed agents signature,certifies the following: } <br /> "I certify that in the pe�formancel of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." i <br /> - S <br /> Signed ------------------------------- Owner <br /> -------- Title 1W----------------------- <br /> I <br /> ?Cer han owner) <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> } BUILDING PERMIT ISSUED --------------------- - ------------------,----------------------------------------DATE ------ <br /> ADDITIONAL <br /> ----ADDITIONAL COMMENTS --------------------------------------------------------------------------- ------------------------:---------------------- <br /> ------------------------------------- <br /> --------- ---------------------------- ---------------- <br /> ---------------------------------- <br /> AV `" -------------------------- <br /> ----------------- ---------------------------------- ----------------------------------------- -------------------------- ------------------------ <br /> ------------------------------------- ---- ---------------------------------------------------- -- <br /> - <br /> - <br /> - ---- ------- <br /> - -- ----- -- ----- <br /> Final Inspection bY- - <br /> ---- -------------Date . <br /> _� <br /> SAN JOAQ IN LOCAL HEALTH DISTRICT <br /> E. H. '1--'68:R ev`5M qa Vtii1 <br />