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FOR OFFrCE'USE'' " ^ <br /> APPLICATION FOR SANITATION PERMIT <br /> r --7 Y5 <br /> (Complete in Triplicate) Permit No: <br /> --------------------------------------------------------- <br /> bate Issued <br /> ---------------------------------_--_--"--------------- 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.i[„nstall the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION , _1- - -------fir'#`--------------/ ------��-�® -- --- CENSUS ;TRACT ---- =� -- <br /> Owner's Name ---Z l- -------- _�l v ---------------------------- ----------------- <br /> 2 <br /> Address Q = --- ---------------------- City i v � _ = <br /> Contractor's Name ------ ----- ---- = ---- - -------.License #/0n I)--- Phone <br /> Installation will serve: Residence.❑ Apartmen,t.HIouse❑ Commercial :❑Tr iler Court ',❑ > <br /> Moteko Other --- --__-------- <br /> Number of living units------------- Number of bedrooms -------- - e,Grinder ----------- <br /> __--.--_ -- Lot Size -- <br /> �,, <br /> s w -- -----------' --------•Private] ,. <br /> Y � Silt, - ------ -- - - -, -------�----------- " <br /> Water Supply: Public System and name - -=--- --------- --_____ <br /> • i -�z <br /> ,t Character of soil to a depth of 3 feet: Sand Q _Clay ❑ t Peat❑ Sandy Loam ❑ Clay Loam ❑ i <br /> Hardpan ii > •^'" <br /> Adobe Fill M t real If es, type ----.-__- "' --_---_-- <br /> f �. _iA­ ��- .- <br /> ❑ Y <br /> [Plot plan, showing size of lot, location- of system in relation to well , buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: �(No sepitic;tank-or_seepage pit permitted if public sewer is available within 200 feet,j_ t I <br /> Size_- _ --------------------- Liquid.PACKAGE TREATMENT SEPTIC TANKDepth `".Z _--_- <br /> Capacit <br /> Type <br /> Materia - Compartments -- ..�- ...... C <br /> t ? >? "_. .- No.r I i <br /> -foundation - _- ---- <br /> Distance to nearest. <br /> Well ----------111--- -- 1 _-----_-__ Pro Line _11 <br /> LEACHING LINE No. of.Lines �_�--------------- :Length of eac =1i ' .---0KZ --------------- Total Length ----p-_Q. . .__ --.--- <br /> `;! t E <br /> 'D' Box:1�__ Type Filter Material _f - --_--_---- epth Filter Material - ---- -- -- ---------------------- ---- <br /> r f r i r . . <br /> Distance to nearest; Well ,�6 --- Foundation J-12-------------- Property Line -1-6..:.....fit-__-- <br /> SEEPAGE PIT [ j Depth ------------------- Diameter NumbeRock Size ------ Rock',Fi'll-A Yes 3 No .❑ <br /> Water Table Depth ------------------------------------------------ <br /> Distance to nearest: Well ------------------------------------ ------------------ p. ine.. _- --------:•-- <br /> • I -..Foundation �P o Y <br /> REPAIR/ADDMON'(Prev. Sanitation Permit# _--_--. ------------------------------------ Date ----_--_------------_--__-__---•--IST <br /> 1Septic Tankr(Specify Requirements) _:__._-,.-_.-------.--------------------------------------------- � <br /> Disposal Field (Specify Requirements); --_-------------------------- -----------------.--------------- <br /> I <br /> __"_-_--- •P <br /> -�;-------------------------------------- <br /> _________________________ ------______ <br /> ___________ ---- --..---.--. ------ -------------- ----- ----•--"------------------- <br /> (Draw <br /> .�a.� <br /> existing and required addition on reverse side) <br /> r I hereby certify that I have prepared this application and that the work will be 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: I # <br /> "I certify that ' the performance of the rk for which his permit is issued, I shall not employ any person in such manner <br /> as to becom su ject to Wor an' Com ensation laws of, California." <br /> 9 <br /> Si ne . .. ----- ------------- - ---- ---- Owne <br /> ii — _% <br /> BY -- <br /> ' ----------------------------------------------------- <br /> Titlef other than owner) <br /> I FOR DEPA TMENT'USE ONLY <br /> ' APPLICATION ACCEPTED BY --- --------------- ------------- ---- ---------------------------=-----------------------. DATE <br /> BUILDING PERMIT ISSUED --------- ----- --------- -------------------------------- --DATE -- -- -------•--•------------ <br /> ADDITIONAL COMMENTS ------- - - ------------------------------------- ----------- -----=--------------- <br /> ----------------------------- <br /> ------ <br /> �' "�"a ------------------------ -- <br /> - ---------- - - - --- - ---:--- ----- ---- i ----- _- ------------------------------- --- --- --- ----------- <br /> 1 i - <br /> Final In <br /> spection � � �` , = Date ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />