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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> v <br /> Permit ------------- <br /> a <br /> - - (Complete in Triplicate) <br /> ------- -- <br /> Date Issued <br /> / This Permit Expires ! 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 Regulations: <br /> !►? C _ - -----------CENSUS TRACT . <br /> JOB ADDRESS/LOCATION -------------------------- ------------------- <br /> P-- <br /> Owner's Name ------ .. ------- ---------- <br /> - - - Phone <br /> -------- <br /> Address3_-Yze� _ r- - / <br /> Contractor's Name 1 - -G! C 1 -License # Phone - - 1 <br /> r4 <br /> Installation will_serve. Residence ❑ Apartment House Commercial ❑Trailer Court ;❑ <br /> . _T _ - ��jj a7 - <br /> -----IC_/�lh-Gi /��. ---- <br /> Motel ❑Other - ; <br /> Number ofIliving units-.-.-/-------- Number of bedrooms ____.__Garbage Grinder ------------ Lot Size ---------------- - - - <br /> Water Supply: Public System and name ---------------------- ------------------------------------------•--------------Private Rf <br /> Character of soil to a depth of 3 feet: Sand'[] Si V] Clay y10 Peat ❑ Sandy Loom -❑ Clay Loam.[] <br /> Hardpan RV 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 seep a pit permitted if public sewer is available within 200 feet,) <br /> --------- Liquid Depth ----- - ----------- <br /> PACKAGE TREATMENT ) ] SEPTIC TAN1C'j Size-• -- i <br /> Capacity Type - No. Compartments ----; ---_ <br /> --- <br /> _��__t__a_-_•.-. <br /> istance to nearest: Well ----l0-�---- -_Foundation 0-- - Prop. Line • <br /> � <br /> LEACHING LINE [,I/ No. of Lines - - --- Length of each line_.---��--dr--`-Q Total Length ___-__ --------------- <br /> '/ i ii <br /> D' Box ___� _ --- Type Filter Material 1 _}� _.Depth Filter Material ��t----------------------;..-_._.__.-1 <br /> - <br /> Distance to nearest: Well ..-� _ ------ Foundation Foundation -_ ------ - =-- Property Line _-.� ----------------- <br /> SEEPAGE PIT Depth � __--- Di X __ Number ____---- "`~------ Rock fie <br /> SEEPAGE Yeso i❑ <br /> ------------- <br /> a ` Rock Size -- <br /> Water Table Depth -----------[---------------- <br /> Distance to nearest: Well ---_--_ ----------------------Foundati C ------_--- Prop. Line --- --------- <br /> e <br /> REPAIR/ADDITION(Prev. Sanitation Permit#---- <br /> - --------------------------------------- Dafie _________� ----------------------- <br /> Septic Tank (Specify Requirements) ---------------- ---------- i •------------------------------ <br /> I Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------- <br /> ------------------------ --------------- 3 <br /> --------------------------------------------- ----------------------------------- <br /> --------- <br /> q <br /> -- ----------- --.---``"-----•-=�t=' "-'==•` ~-----` -. .------------------------------------------------------------------- <br /> (Draw <br /> - -- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that Ir have prepared'.this, application and that the work will be done in accordance with San-Joaquin <br /> i County Ordinances, State Laws, and Rules;:and'Regulations of the San Joaquin Local Health District.Aome owner or licen- <br /> sed agents signature certifies the following: - �s p , <br /> ''I certify that in,the performance of ttie-work;.for which this Permit is issued, i shell not employ any person in such manner <br /> as to become subjec <br /> tWJ,rJcma s Com ensation­Iaws of'CaliforniaOwner <br /> Signed -- --- - � <br /> ..: ------ ------ <br /> i ------------- --- -----` Tit e -------- ------------- ------------ <br /> I (If other than owner) ��-,:W� "` '~Rrw •� <br /> 'FOR. DEPA1tTMENT'USEVNLY <br /> APPLICATION ACCEPTED BY li------------------------------= ---------------------------------I------------------ DATE <br /> BUILDING-PERMIT-ISSUED 3 �i DATE -.. <br /> ADDITIONAL <br /> . COMMENTS'--------- ' <br /> ------- --t---.--,------ -------r-----t- <br /> -------------------------- ----------- <br /> y-�--------------- <br /> ` ---•------- <br /> -------------------------------------- -- ----------------------------- <br /> ----------- .----- -- -- /--------- ---- - -- <br /> : <br /> FinalInstnb � w <br /> ecio <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C/_3 <br /> E. H. 9 1-'68 Rev. 5M <br />