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FOR OFFICE USE: APPLICATION FOR SANITATION PERM <br /> ...................•---•--............_.. No, <br /> fM Permit .................. <br /> . �, ,� lCompfee in Triplicates _ <br /> ................................. -a f1 77 <br /> •-------•-•- ....----•------• ------.I....... <br /> This f em+lf Expires} Year,front Date Issued Doti Issued <br /> 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 County Ordinance No. 549 and existing Rules and Regulotions- <br /> ; 41 <br /> , <br /> r� <br /> E <br /> I <br /> CENSUS. .... RA <br /> AC�T�------9 <br /> -JOB ADDRESS/LOCA • --•---. -Owner's Name ........... ---A ....-• -----•. .......... ....-Phone <br /> ---- <br /> 1 <br /> a <br /> Address ---- ....._I.7..?..,r'Q .......:.`T! .. ._7...........:. if._....._.. ..City ...�r ._...._.._.._ <br /> Contractor's Name ..... r"-1.41------------------------ -------------------�`----- ---------License # .........-_- ------- Phone ..... ------------_--------- <br /> Installation will serve: Residence 0 Apartment Haase0 Commercial UrailerCIM4$ <br /> Motel ❑Other .. <br /> Number of living units:__3------- Number of bedrooms ....:_-..Garbage Grinder ............. <br /> lot Size ----•--...-- -- ----•••••--.._---.. <br /> Wa#er Supply. Public System and name %.� <br /> _..........�... ............ - .Priv <br /> 0 <br /> Character of soil to a depth of a feet: Sand❑ Silt❑ Clay 0 Peat Q Sandy Loam Q Clay loam Q <br /> Fill Material ............if yes,type............... ......... .. <br /> Hardpan❑ Adobe <br /> (Plot plan, showing size of lot, location of system in relalIon to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( SEPTIC TA" Siae� /Ifi. .--.. '�..'.yLiquid Depth . s!.. <br /> /f_s`a_.:_._ T �+' Material.._�`..:`..... .. No. Compartments ' <br /> Capacity Typed-6,4— -.. ...... --.- •..................... <br /> st f.(#p.Eco ...............Foundation ZIP..0.�y........ Prop. line .. �J... <br /> Distance.to-.nearest: Well __ <br /> LEACHING LINE No. of Lines ----------- - Length of each line........ ............. Total Length ............... <br /> 'D' Box .T ►----- Type kilter Material-em........ Depth Filter Material ./Y.1............................... <br /> Distance to nearest: Well --------foundation Property Line 'Z'.4............ <br /> S Depth ........:. teeter 'Y- `�. 2. Number ........./........_....... Rock Filled Yes•- No 0 <br /> ffhock Sire -- /! <br /> Water Table Depth f R®�--------- ....................... �[".''��.-•---............ � <br /> f <br /> Distance to nearest: Well ..................�CPQ.......:. <br /> . Foundation --•---- Prop. Line ...................... <br /> REPAIR ADDITION Prev. Sanitation Permit# •• � ----- Date ................................... <br /> E <br /> r Septic Tank(Specify Requirements). ..............................................--......................................................... <br /> Disposal Field (Specify Requirements) .............................`•...........................................................-........--•........................ <br /> ..---...._. s <br /> ----------------------------------•-­-------------------------------------- .._..----•-••• -•---- -•------•••••••-•-..........:......------------------- ..................m........... <br /> , <br /> -------- - --- ---- - ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and #hat the work will be done in accordance with San Joaquin <br /> Cow ty Ordinances, State Laws, and Rules and Regulations.of the San Joaquin Local Health:District. Hance owner or licen- <br /> sed a encs signature certifies the following: <br /> "I c y that in the perfo ca.of the work for which chi s permit is Issued, I shall not employ any person In such manner <br /> as td. come subloct to rkman's Compensation laws of California." <br /> Y <br /> s <br /> Signe - - - •�"4` ------------ ------ ------- ---- ---------------------------- Owner <br /> r BY <br /> �1......... Title -------------_------------ ---- -- ------------------------- <br /> ----------- <br /> (if <br /> -- ---(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> . _- PATE ��>..-APPLICATION ACCEPTED BY -.4o- .... . <br /> BUILDINGPERMIT ISSUED ------------- ..................... -- ..................._......-.--------------------------- _...-:DATE --- .-._....---=------... <br /> ADDITIONALCOMMENTS -•----•--=-----•------•--....--•.....................'�. ----_...-----------•----•--•-••----------- --------------------__................ <br /> ...... I - •----------------. :_._..-:-- •-•--•-•.. -•.........-------------------- ...... ............... <br /> ----------- -----------------•-------•------•-- --• <br /> -----•----------------- •--•------•-----._....------------ ._........, <br /> l <br /> ... ..... <br /> _Date -- <br /> Final inspection by: _ . __ . . ................. .. . . <br /> EH 13 24 1-68 Rev. 5 SAN J0,4QuIN LOCAL HEALTH DISTRICT 8/71 3m <br /> i <br /> 3 <br />