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:,FOR OFFICE USE: <br /> A APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. ._'----------•--- _ <br /> ------- ---- - ---- <br /> - ------ ------ <br /> This Permit Expires 1 Year From Date Issued ©ate Issued <br /> Application is hereby,made.;to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> l described. This applicationlis made in compliance with County`O Ordinance No. 549 and existing Rules and Regulations: <br /> ti� -71,ADDRESS/LOCATION ___ ---� -- - ,(rI ----_._CENSUS TRACT -------------------------- <br /> Owner's <br /> --------------__- __ <br /> Owner's Name ------- --------- Phone <br /> Z <br /> Address ---- - <br /> -------------------------------------------- <br /> . � - Cit �° -----�.- ------ <br /> Licens <br /> Contractor's Name Y Phone -9%4-7-p 07--- <br /> Installation will serve: Residence Apartment 1_4House Commercial :❑Trailer Court ;(] <br /> Mote Other _ <br /> Number of living units..---/.-.-- Number of bedrooms -_4 <br /> - -._- <br /> �,_---Garba�ge" /Grinder - --- <br /> --_--•_ Lot Size -.--T _____________ <br /> Water Supply: Public System and name ----------------_________ _-Y�- gr Private E]- ------ <br /> - ----- ------------------------- <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat❑ Sandy Loam [D Clay Loam.E] <br /> Hardpan ❑ Adobe Fill Material --- -F-- if y„es, 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,j <br /> PACKAGE TREATMENT � <br /> [ ] SEPTIC TANK'[ )5_1 <br /> -------- -- ----- <br /> -- Liquid Depth ------ -----------.•-•-- <br /> Capacity <br /> l <br /> .___- - Type -�"1- ___ Material--. --_ No. Compartments � <br /> Distance to nearest: Well ------------------------------------Foundation I----1O_ �I <br /> ryr Prop. Line --1 d_..----.-. . <br /> LEACHINGfINE { ] No. of Lines -------c�------------ Length of ichl-lin � <br /> t <br /> .-�- -- g �-- .�.--�-� - ---....--- Total Length .--1�-d-------------- <br /> )!*7D' Boxk^, -- Type Filter Material -- - <br /> 4 ----- - --Depth Filter Material _.--_��_--___-_ _ <br /> Distance to nearest: Well ___-----_.--f Foundation --- D---.._-------- Property Line -- -_.-_--- --__ <br /> SEEPAGE PIT De �'- 'S.. �v� „i -„�,. <br /> [ ) Depth ---- -.,•---,----- Diarrmpter - 3A_------ Number ------__�------------ Rock Filled Yes Z No i❑ <br /> Water Table Depth'"y i<:%_-_-- _ - Size <br /> Distance to nearest: Well ------------. N4 t--0--- L i <br /> -� -------------------Foundation -_l-d--------- - Prop. Line -•--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----__-.--------------I--------_--_______ Date -------------- ------ - -- <br /> 1 <br /> Septic Tank (Specify Requirements) -------------- --------------__ <br /> Qy <br /> Disposal Field {Specify Requirements} --------- _ ------------------ ----------- ---- <br /> - --------------------------- <br /> __-_---._•------------- --- -------------------•-__------------ ------_.----__-_---__---"--- - <br /> - _----"----------------------'------------------------ <br /> -------------------------------------- --- _ <br /> (Draw existing and required adNition on reverse side) t <br /> I hereby certify that I have prepares' _t is app icatiori and fh'af fhe work will !s`e done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the'San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of' I i <br /> 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 . It - ----------- --- ---------------------- Owner- --- --------- ----- -- _ <br /> By <br /> � <br /> --- ----------- <br /> (If other th <br /> ---------- ------ Title ------------------ <br /> ----------------------------- <br /> owner) t <br /> FOR .DEPARTMENT USE ONLY <br /> �APPLICATIO�NACCEPTED 13 ti DATE DING ISSUED --------------- <br /> ` DATE <br /> A41TI,7NAL COM ENTS --- , t� === == _ = = = <br /> gAVI _sem---- -- _p 4c is [�-- l ' ----------------------------- <br /> ------------------- - rt ------------------------------------ - <br /> -- - --- ------------------------------------------ <br /> -------------- <br /> ----- ---------- <br /> �r <br /> Final Ins ection b <br /> - --------------------------------------------- ------- --------- - ---- - <br /> p � - ---------------------------------------- --------Date------- <br /> SAN <br /> ----SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> E. H. 9 1-'68 Rev. 5M• <br />