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F1JR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................ .................................. <br /> (Complete in Triplicate) Permit ..................... <br />.......... <br /> Date Issued ..SR.�7.76 <br /> 1- f...�..............•--............ This Permit Expires 1 Year From 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulotionsa <br /> JOB ADDRESS OCATION .._.Z3..7- ..... � �Oi� ,?�� �,ENSUS TRACT .......................... <br /> Owner's Name -.. <br /> ..��.TC-------...���---•-•----•........................ ...................................Phone . .�6�& <br /> Address ............City . <br /> Contractor's Name -__ # .a1..73.. Phone <br /> ......... ...... <br /> Installation will serve: Residence rtmont House❑ Commercial❑Trailer Court ❑ <br /> Motel❑Other............................................ <br /> 3:.....Gar a Grinder Lot Size ...ZA*r:r:- <br /> Number of living uni#s:_....�.... Number of bedrooms bag ............ ............ ............ <br /> Water Supply: Public System and name .--- ----- -/�----------•-.._....................__...................................................Privai 0 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Foot❑ Sandy Loom 0 Clay loam ❑ W <br /> Hardpan❑ Adobe❑ Fill Materlol............ 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.)r <br /> NEW INSTALLATIONS (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) V <br /> PACKAGE TREATMENT ( j SEPTIC TAMC Size...�,:lX.. .. 15...9................... Liquid Depth .......................... <br /> Capacity,1.2�. Typo&,6. egrl-Material.-n '. t o. Compartments ....Z. .......... <br /> Distance to nearest: Well oxer. .................Foundation 1 a... Prop. Line ..../OQ,.,,,- <br /> LEACHING LINENo. of Lines .........7---------- Length of each line........7 '........ Total Length ......1. .'...... <br /> 'D' Box / Type Filter Material Depth Fitter Materia! ............lel ' <br /> Distance to nearest: Well ./P) ........... Foundation ......:�Q.......... Property Line ........................ <br /> SEEPAGE PIT Depth ......?_-�..... Diameter ....,M3."'Number ............ --........ Rock Filled Yes EY--'No C3 <br /> Table Depth ,,7.Q...........................Rock Size --....Y <br /> Distance to nearest: Well ......,16- . .................Foundation ...../.,d:-'...... Prop. Line ...l4.J........ <br /> REPAIR ADDITION Prev. Sanitation Permit# ............................................ Date ..................................) <br /> SepticTank (Specify Requirements) ..............................._................................................................._............................I............... <br /> Disposal Field (Specify Requirements) ....................................•-----....... ---------------•-------------.------.----- <br /> --...-----•-- ------------ ------------------------------------------------•--- -------••-----...-•-•--•--•--•--••---•---•---.............-----•........................................I....... <br /> •---------------------------------------------------------•---- ............................................_........................................................ ................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be-done in acewdmee with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.©istrid. Monte ewner or licew <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed AxAen: . .... Owner <br /> By , J .-_--------- ............. ...------------............ <br /> -. :tie <br /> (if other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ..... DATE <br /> BUILDING PERMIT ISSUED ------ ------- ----------- <br /> ---------------- <br /> ......•...... <br /> .---------------- <br /> .--------------------.....DATE -_...-................................... <br /> . <br /> ADDITIONALCOMMENTS ------ ---. ......................................•- -----•. --..:_---._................................ ------ ..............................-... <br /> FinalInspection by: .............. C- ...................... ----•--- ............................. .. .2 �a..........--- <br /> ...-....Date ......�....------•---- -- <br /> EH 13 24 1-68 Rev. 5m SAN JOACQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />