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FOP OFFICE USE: APPLICATION FOR SANITATION PERMIT — s'7 <br /> Permit No. ".75 <br /> (Complete in Triplicate) <br />_ _...�.,:--��-.•,�!. ..................... Date I55U@d Z4 . <br /> This Permit Expires 1 Year From Date issued <br /> DistrictI Health <br /> Application is hereby made to the San Joaq Pc <br /> described. This application is made in copian ewi h CountyOrdinan a permit <br /> and existing install <br /> Rules�and Regulations,ein <br /> ti. _, , .. ..CENSUS TRACT <br /> JOS ADDRESS/LOCAT ON - - r ---Phone .- _-•.........................•-- <br /> H-Owner's Name �------ •�- � ._rK.�:.�:._.............. ......._...... <br /> Address /�. - - ----- License...# 34 !._ Phone .............. .............. <br /> . city ........................ <br /> /Y <br /> Contractor's <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other --------------------•-----------------.---•- <br /> Number of living units:_......[_... Number of bedrooms _.. -___.Garbage Grinder _.......-... Lot Size --- <br /> Water <br /> - Private <br /> --__..._•.---- " ------------••------ ----------- <br /> Water Supply: Public System and name __-------------------_ Cla Loam <br /> Peat Sandy Loam Y ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ ❑ <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 seepage pit permitted if public sewer is available within 200 feet,) <br /> SEPTIC TANK[ ] Size...--•--•--------------- ---------••--- ---- Liquid Depth 6 <br /> PACKAGE TREATMENT [ ] - No. Compartments <br /> Capacity . Type --•---. • ---- Moterial----------.-""-"---- <br /> ll ...."-- - -- Foundation ...................... Prop. Line ------------ -------- <br /> Distance to nearest: We0 <br /> LEACHING LINE [ ] No. of Lines "-"-- ----------- Length of each line ---------------- Total Length -----------------------••--. <br /> ..._ � .............••-----.,.-- <br /> 'D' Box -- .-------. Type Filter Material --------------------Depth Filter Material ................... <br /> -----•-•--- Foundation ..- ••--.....— Property Line ------- ------ <br /> Distance to nearest: Well -..•------•- No ❑ <br /> ---. Number -------------- ----... Rock Filled Yes ❑ <br /> SEEPAGE PIT [ � Depth .. _ Diameter ._..._.._.- r <br /> - Rock Size ---- --------------------------- <br /> Water Table Depth -------•---•-------••------- <br /> Distance to nearest: Well ----_-----------------------------------Foundation .. Prop. Line ..-----•-----•-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# <br /> -----•--------"------ Date -----••-------••----••-------•----] <br /> Septic Tank (Specify Requirements) - _.._ <br /> Disposal Field (SPpecify Requirements) ._-114"rIe/...... <br /> O <br /> ------ <br /> ---- --- w _c <br /> - ... . <br /> - -- <br /> ...... (Draw existing and required addition on reverse side) <br /> I hereby certify that i have prepared this applica <br /> tion <br /> f=onsnd that <br /> of the San Joaquin Local District. Homewith <br /> ow owner or I Cen- <br /> County Ordinances, State Laws, and Rules and g <br /> sed agents signature certifies the following: r which this permit is Issued, I shall not employ any person in such manner <br /> " 11 certify that in the performance of the work fo <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -- _-- TitleOwner �. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------•-- ......................................... ------ ---- --••--------••---------------• DATE ...rt) <br /> BUILDING PERMIT ISSUED _--_--•-------••--------- ----------- <br /> ADDITIONALCOMMENTS --------.-----------------------------------............................ ._.. <br /> .... <br /> ............... <br /> •--...• <br /> Final Inspection b --- ......... <br /> ................................... <br /> -•... ................•-....--•-._ <br /> Date .._..... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7172 3 M <br />