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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------- - ------------------------- Permit No. <br /> (Complete in Triplicate) <br /> Date Issued <br /> --------------------------------------------------------- ✓ This Permit Expires I Year From Date Issued <br /> 173 -1 -33 - 0-5 <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 Regulations: <br /> q0.64e <br /> JOB ADDRESS/LOCA;101�Nl�t--ID+--W.---t�- - ----- -------------- ------- ---- ---------CENSUS TRACT -------------------- ---- <br /> Owner's Name _—_ U-- - ---- ------------------------------------ ---Phone --------------------------_-------- <br /> -----------_--- Ci -,t--------------------------a------% ------ <br /> Address -------------------------- --- --- --- City _,21 <br /> 6 <br /> Contractor's Name -------- ------- ---- -_ License # ------- & <br /> --------------------------------------Lice __ _.q ---9_4--Phone' ------- ---- <br /> Installation will serve: Residence ®Apartment House 0 Commercial E]Trailer Court !F] <br /> Motel ❑ Other ----------------------- -------------------- <br /> --- Number of c1l Garbage Number of living units:-_.__ G,'nder.,&'_4_:___,. Lot Size -__!l ld:5A.J��------- <br /> ------------- <br /> Water Supply. Public System and _t--- cc 11ii --Private El <br /> N----------------- ------ <br /> Sa cly_�� .0 Clay Loam '[:] <br /> - 1 1 a m <br /> Character of soil to a depth of 3 feet, Sand'[-] Silt Clay El Peat FEI I <br /> Hardpan ❑ Adobe Fill Material _#`V'�- 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 seepage pit permitted if public sewer is available within 200 feet <br /> PACKAGE TREATMENT SEPTIC TANK � Size XY- - - Liquid Depth <br /> - -------- <br /> Capacity - -- ------- Type Material&I �_-No. Compartments ........ <br /> Distance to nearest. Well ____________________________________Foundation ------- Prop. Line ............ <br /> -�;. ............... <br /> LEACHING LINE No. of Lines _____I_________________ Length of each line------------qd------------ Total Length <br /> _4------------------------ ...... <br /> D' Box Type Filter Material ----- epth Filter Material <br /> Distance to nearest: Well ----­`----------- Foundation .............. Property Line ........ <br /> SEEPAGE PIT fy1 Depth Number ________r_________-------- Rock Filled Yes [Z_--ffo 0 <br /> ----- Diameter ---;� �ti�l <br /> Water Table Depth ------0-------------_-___--------Rock Size --- <br /> Distance to nearest: Well ------- —-­--------------- Foundation --- Prop. Lina:!5._ -- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ______._________________..._______) <br /> SepticTank (Specify Requirements) ---- ---------------------------------------------------------------------------1-....-------------------------•<_--------------------------- <br /> Disposal <br /> .1------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------_-- ------------------------------ --------------------------------------------------------- --------------- <br /> ------------------------------------------ ------------ --------------------------------------------------1-1---------------------------------------------------------------------------------------------- <br /> -------------------------------- ----------- ---------------------------------------------------------------------- ---------------------------- ---------------------------------------- <br /> .(Draw existing and required addition on_rev_eJe side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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: . d 'hall not employ �ny person in such manner <br /> "I certify that in the performance of the work for which this perm.itlis.iisues <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed ------------------------------------------ -- ----------- -- -- ------—-----------: Owner <br /> By --------------------- ---------------------------- --- --- ------ ---------- <br /> (Ef other other than ow --------- Title <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---'red------ ------------ DATE <br /> ------------------ -----DATE ------------------- -------------- <br /> BUILDING PERMIT ISSUED -------------------------- - ----------- <br /> COMMENTS ---------- ---- ------PJ3­,01Tr----------------------------------------------------- ------------------------- <br /> -----------------------------------------------------I------f-i�--- -------1,-NM <br /> --------------------------------------------- ---------------------------------------------------- ----------------------- <br /> ----------------------------------------------------- ----------------------------------------- ------- -------------- ------------------ -------------------------------------------------------- <br /> ------------------------------------- ---------------- <br /> P <br /> ------ --- <br /> Final Inspection by: ---------I-:e/l --- -------------------Date <br /> SAN JO;Qrul--N—LOCAL—H-E--A--L--T--H-----DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />