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FVR OFFIU USE: <br /> APPLICATION FOR SANITATION PERMIT G9 <br /> ................................................... (Complete in Tripllcatef Permit 61w�Z .....}:... <br /> .............................................. - oars Itis ed <br /> This Permit Expires 1 Year From Date Issued <br /> Appllcatlon`ic hereby mbde`to the San Joaquin Local Health District for a permit. to Construct and Install the work herein <br /> described. This application Is made`ln to Ilrn ,lth C//ounty Ordinance No. 544 and existing Rules and Regulations, <br /> ,SOB ADDRESSA TION .L.I..��.Ael.�.. r1....... ........................CENSUS TRACT <br /> Owner's Name .� �... '� r... ...CA...............E� . ..................Phone `U -, . <br /> Address I.�T.............. <br /> ... ...... ...... �._..,._. City ...--''" ....................................... .... <br /> � �.. Phone p� <br /> Contractor's Name �ci'..- e' .. .. ......,. ..Ucense ........ .... ..... .�-�.4�. <br /> Installation will serve, Residence(Apartment House 0 Commercial OTrailer Court 0 <br /> Motel❑Other............................................ <br /> Number of living units:...... Number 'of bedrooms . C...Garbage Grinder ............ Lot Size ............. ` ------------------k,.43 <br /> Water Supply: Public System and nafne :. =.:..'...... ` .......:........... .....................:....................Private ❑ �} <br /> Character of sail to a depth of 3 feet: 1, Sand n Silt❑ Clay Q Peat❑ Sandy Loam fl Clay Loam 0 ,� <br /> Hardpan E3 Adobe Quill Material ....... ....If yes,type............... .............� Y <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed fon reverse side.) <br /> NEW INSTALLATlONa (No septic Tank or seepage pit perrriitted if p lbllc Dowers available within 300#eel,) V w <br /> PACKAGE TREATMENT [ SEPTIC TANK Size..... .... ...................... Liquid Depti9` <br /> ' Capacity : <br /> ....... Tyr. :�. Material_. ..... No. Compartments .. .r..-•-......... <br /> i , - <br /> Distance to nearest: Well' ..ti.... ... ..{ ._.......Foundation .... ....... Prop. Line .....�.��.......... [ <br /> LEACHING LINE No. of Lines /.................. . Length-of each One. Total Length ............ <br /> 'D' Box --- `� --- Type Filter Material. . . .Depth Filter Material .... ��................ .. ..... <br /> . -- . .�.. <br /> I ...... Foundation f......... Property Line ... ... <br /> • � Distance to nearest: Well .�.�r�,l. ............ l ��............. <br /> SEEPAGE PIT Depth ......... Diameter .. .`... Number ------/......... Rock Filled . Yes No C3 <br /> Water Table, Depth _.._ ..................Rock Size -.---. ...X..:��...... <br /> I / <br /> Distance to nearest: Well ....1'4-. ..........................Foundation .: .1-�.%..._. Prop. Line ......� .._.•--.- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I A <br /> Septic Tank (Specify Requirements) ...................................... •- . ---- -•...................................................._. ............... <br /> Disposal Field (Specify Requirernents) ............................................................... <br /> .......................... ..................._....... ' ...................................................................... <br /> ....-•---•............................................... .. ................................................................... ....................................................................... ! <br /> .......................................................... .................._�...-....... :...._......._....................::.......... .........................._............................... <br /> Draw existing and reqaired addition on reverse side) <br /> 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 liten- <br /> sed agents signatuire certifies the following: <br /> "I certify that in the performance of the work for which this permit Is Issued, 1 shall not employ any person In such manner <br /> as to bec a subject to man's Compen tion to of California" ` <br /> Signed ..-...�. F �'in�.�-Q..�... - ............. r <br /> By .............................................................. . .. . . ..�`. ._......------- Title ................................. <br /> ..... <br /> [If other than owner) . <br /> FOR DEPARTMERT U,SE ON <br /> n <br /> APPLICATION ACCEPTED BY............:........... . �.. DATE ..... � :...:.............: <br /> BUILDING PERMIT ISSUED ' .. . ...........:....DATE ........................................... <br /> ........................•---• .... ........ ....... <br /> ADDITIONAL COMMENTS ' ..........................................:........................... <br /> .................................................. .! ---•-•---------•--•.................................---...............................................................................---... <br /> ........... <br /> :n....................................I................. .......•---------..............--..............--.. ......--...............----...........-.........................I...................---- <br /> ...... .............. . ................._. <br /> i a Inspection by: X....-.Date ..... .` �..-.... ••------------- <br /> EI i3 24 1`68 Rov• 5H SAN JOAQUIN LOCAL HEALTH RIOT 8/7h 3M W <br />