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FOR OFFICE USE: <br /> ----- -----------------------:05- ................ APPLICATION FOR SANITATION PERMIT <br /> ---------------------- - -- -- ----------------------- (Complete in Triplicate) Permit No. <br /> -------------- <br /> —-------------------- <br /> This..Permit Expires I Year From Date Issued Date 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 ' ode in compliance with County Ordinance <br /> 2 A_ s <br /> & E A- No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION LCA r <br /> ------ ---- <br /> Owner's Name ------CENSUS TRACT <br /> Address _.__ , !Y' - I -- ---------- ------ ------- ................ Phone <br /> ____--------------- .7 1 ----------------------- ------------ <br /> - —1------------ city <br /> --------------- <br /> Contractor's Name ------- _4 <br /> ---- --------------------------------- --------- <br /> ------------- <br /> --------License # �IIZ3--- Phone <br /> Residence partment House[] Commercial[DTrailer Court 0 <br /> Installation will serve. El A ----- ---- <br /> Mote <br /> 7_Number of living units:____.:_____ Ixother e <br /> ----- Number of bedrooms ________..__Garbage Grinder ------------ <br /> Water Supply: Public System and name Lot Size ------------------------------------------- <br /> ----!'27 --------Private El <br /> Sand' Silt Clay F Peat E] Sandy Loam E]t 'Clay Loam <br /> Hardpan 0 Adobe <br /> )qFill Material ------------ If Yes,type --------------- <br /> ............. <br /> (Plot plan, showing size of lot, ..location of system in relation to wells, buildings, etc. must be placed on revers'e0side.) <br /> NEW INSTALLATION <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet, <br /> PACKAGE TREATMENT SEPT - I S. <br /> I�TAN <br /> z <br /> Capacity 1ze4---X----95-�X le2-_`�------------- Liquid Depth ---------- z, <br /> Typ Compartments ------F!!�_ N <br /> Materiale- '­ZONo. Compa <br /> LEACH Distance to nearest: Well -----------------Foundation <br /> ING LINE No. of Lines -17� ---------- Prop. Line ---------------------- <br /> - -------------- Length of each line----/eam_ <br /> ----- Total Length - -------- <br /> 'D' Box __/--_--- Type: Filter Material 151,64�<&_Depth Filter Material ---- <br /> Distance to nearest: Well ------ Foundation _Zcpc�_, Line V'Allk- <br /> SEEPAGE PIT Depth --------- I -------- Property ----•------- <br /> ---------- Diameter ---------------- Number ---- ----------------------- Rock Filled Yes No <br /> Water Table Depthl-j— <br /> ,0.J I i------------------------------------------Rock Size <br /> Distance to nearest, Well ------------------------------ ...... Foundation p <br /> REPAIR/ADDITION(Prev. Sanitation1�1 Prop. Line A <br /> . Permit, _- Date i--------------- <br /> Septic Tank (Specify Requirerflents) ............. <br /> -- <br /> ------------- ----------------------------------------------- ---------------- <br /> - ------- <br /> Disposal Field (Specify Requirements) ---------- - - - ------------------------------------------------------------------ -------------------------------------- <br /> - ----------------- <br /> e -------------------- ------------------------------------ <br /> --- ------------ <br /> --------------- <br /> ---------:-----------------------------------------------------------------------------------------------------I--------------- <br /> ------------------------------------------------------I--------------! --------- - I . - ------------------------------------------------ <br /> __ ­ ------------------------------------------------------------ <br /> (Draw _a-n4 required addition on reverse side) <br /> I hereby certify that I have prepared thisI application and that the work -w Ill be done in accordance with Son 'Joaquin <br /> County Ordinances, State Laws, and Rules and Riiulations of the San Joaquin sed agents signature certifies the following: Local Health District. Home owner or licen- <br /> "I certify <br /> as that in the performance of fhe�work for which'this Permit is issued, I shall not employ any person in such 1 <br /> to bec7e subs to ork Ws C manner <br /> ens laws, f California." <br /> Si ned <br /> By ---------- ---- -- ------------ Owner <br /> ----- ----- ------------ ------ --- I <br /> (If other than 0 er) -- ----------- -Title ------------------- - <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By- --- ----------- ........... <br /> BUILDING PERMIT ISSUED ------------------------------------------------- --------- DATE <br /> ----------------------------------------------------------- --DATE <br /> ADDITIONAL COMMENTS <br /> 7------------------ ------------------- ---------------------------- <br /> ---------------------------------------------------------------------------- ---------I <br /> -------- --------- ----------- A— <br /> -------------------------------------------- ------------------------------------------------------------- <br /> -------- --- ---- ----- ---------------------------------------- <br /> Fi------------------------------------ ------- ------------------------------------------------------------------------------------------------------------------ <br /> nal Inspection by: -------- ------ -- ------------------------------------------------------------------------- ----- <br /> ------------ --Z ---------- ------- <br /> ------------------------------------- ------------------------Date <br /> SAN)OAQUIN LOCAL HEALTH DISTRICT -----------------k <br /> E. H. 9 1-'68 Rev. 5M. <br /> ---------- <br />