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FOR OFFICE USE: %0 f <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- <br /> ------------------ Permit No. <br /> - --------=-------- --to-------------------- (Complete in Triplicate) <br /> Date Issued i---Z6,� <br /> ------------------ <br /> ---------- This Permit Expires 1 Your 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 compgance with County Or ante No. 549 and existing Rules and Regulations. <br /> 3/ <br /> JOB ADDRESS/LO TIO - ----"'"--l___'_--- -— ------------------------- -------- <br /> bN -- ---- - ---------------­---- ------- ------ --------CENSUS TRACT ----------- <br /> Owner's Name -T r-tk ---- -- -- ------------ --Phone ----------------------------- <br /> Address -----------`>70 -------T-f---l- <br /> -- --- ------- . ....... City ---------------------------------------- <br /> Contractor's Name ------- <br /> Installation will. serve: Residence Apartment HouseE] Commercial FlTrailer Court 0 <br /> Motel E]Other --------------I--------------------------- -- <br /> Number of living units:--- ------- Number7`of bedrooms -Garbc�ge Grinder ------------ Lot Size ----------------------------- <br /> -n -5------11 - ---/-A <br /> Water Supply: Public System and name ---------------------------------------------­------------------------------------ -------------------------Private <br /> Character of soil to a depth of 3 feet. ISand'E] t El Clay .0 Peat Ej Sandy Loam E] Clay LoomC] <br /> Hardpan 5? Adobe 0 Fill Material ------------ If yes,type ---------------------------- <br /> ate <br /> (Plot-plan-� showing-size of lot, -lo'c'o-tion' o <br /> of system in relati' <br /> n 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-______---------------------------------- quid Depth ------------------­ <br /> Capa u <br /> -----------I-------- Type -------------- ----- Material---------------------- No. Compartments -------••- .- �I <br /> : Distance <br /> ------------------ <br /> Distance-to-nearest.--Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE ]*, .Nd. of Lines ----------------------'Length of each line-------------.---.---.-____- Total Lenqth--- %-T ------------ ---------------- <br /> e <br /> 'D' Box --- - ��-e,.FiW�,,Material!-- -------- --------Depth Filter Material --------- ---------------------------------- <br /> Distance t6% nearest: Well ----------------- ------ Foundation ------------------------- Property -Line ----------------- <br /> SEEPAGE PIT-[-]­--D-60th -------------------- Diameter ---------------- Number -----------------------------Rock Filled Yes El <br /> I No <br /> 1-C1r! ,f-�J2,,W,qter Table Depth ------ ---------------------------------------------Rock Size ------------------=------------- <br /> Distance to nearest- Well ----------------------------------------Foundation -----------/------ Prop. Line ------------------- <br /> REPAIR/ADDITION(Prev, SanitatinPermit f- -------- ----------------------------------- Date --------------------/._--_---_.-) <br /> Septic Tank (Specify Requirements) ---------- ------------------------------------------------------- --------- <br /> -------- <br /> ----------------------------------------------- <br /> a ie e.-I --------- <br /> Disp I Fi 1_*(Sp?ec!,fTy R6q <br /> So, <br /> --------------------------- <br /> ------------- - ----- ----- ---- ---- ------ ---- ----------------------I--------------------------------------------I------------------------ <br /> --------fV <br /> -------- - X- - - ---------------------------------- - ------ <br /> -------I--------------------------------------------------- <br /> Dexis exist and addition on reverseside} <br /> I,hereby-certify,that-I-have prepared this applicatio-n-and that the,work *ill-�16-e-dam-e iff-ca—corII1W &h <br /> dUfi?e WS <br /> .i Joaquin` <br /> County Ordinances, State Laws, and Rules and Regulations.oF the Son Joaquin.Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which thWp <br /> as to become subl to Workman's Compensation laws of C efmit is issued, l shall not employ any person in such manner <br /> Workman's <br /> alifornia." <br /> Signed -------- ------- -- ----------------- A n,er <br /> ------ ----- ----------- --- ------ Ow <br /> & <br /> By ---------------------- -- - IV U �- I _, e <br /> ---- - - - --- ---------- ------- --------- Title ..... . ..f ......... - ----------------------------------------- <br /> (if otMr than owner) <br /> FOR DEPARTMENT/USE ONLY <br /> APPLICATION ACCEPTED BY e� --------- --------------------- ---- DATE 00!_-r- ---------------------- <br /> 11 ------------- <br /> BUILDING PERMIT ISSUED --- -------------------------------------------------- - / -- <br /> -------- DATE ------------ -------- ---- -------COMMENTS --------- = ------ <br /> -6�--------------------------------------------------------------------------------- <br /> -----------------------------411 <br /> --- --------------------------------- --------------------------------------------------------------------------------------------------- <br /> -------------------- ----------- <br /> ---- --------- -- - ------------ <br /> Final Inspection by; --- <br /> --------------------------------------- -------------------------------.Date 1�? ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. <br />