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FOR OFFICE USE: <br /> ----------- -------------------- APPLICATION FOR SANITATION PERMIT <br /> -- Permit No. -- ---------- <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- <br /> ___-----_------------------------------------------------ This Permit Expires ] Year From Date Issued <br /> Date Issued _.. _f=._---L_. <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 /> JOB ADDRESS/LOCATION "- 132__140_.____0 Ve <br /> ---------------------- ----CENSUS TRACT <br /> Owner's Name --Dori---CLi aalrigha-M------------------------------------------------------------------- -------Phone -- 466-7-581------------ <br /> Address ---- --Sae----------------------------- ----- •--- - ---------------------------------- - Citv fit-kms�---------------- <br /> --•----------------------.._..---------------- <br /> Blackard'sContractor's Name Septi"e"" Tank <br /> --------------------------License # --26.8.951------ Phone ---4fi3.-7-Q_4a------ <br /> Installation will serve: Residence] Apartment House�❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:-----_1___ Number of bedrooms _2--------Garbage Grinder ------------ Lot Size _._-6Q_9X80_'______________________ <br /> Water Supply: Public System and name ------------------0-ity-------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ .Peat ❑ Sandy Loam -E] Clay Loam C] <br /> Hardpan ❑ Adobe.En 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT '[ ] : SEPTIC TANK'[ ] Size----------------------------------------- Liquid Depth .--_---_-------__.__-_-. <br /> —C-apacity ------------------- Type -------------------- Material---------------------- No. Compartments ------ --------------- <br /> Disid-nce to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---.---------.__-__-_. <br /> LEACHING LINE [it No. of Lines -------I--------------- Length of each line--------- Q_....... Total Length ___40_'.................. N <br /> ` 'D' Box ------ ----- Type Filter Material -----2------------Depth Filter Material ---________lg"_ ._ _"-____._ <br /> - ------------- <br /> Distance to nearest: Well _____ ______ Foundation -------/e_1_______ Property Line _____,ll2---,__-_._"- <br /> SEEPAGE PIT J] Depth ----25-'--------- Diameter _.__33-1_____ Number -----------1_-------------- Rock Filled Yes E) No D <br /> Water Table Depth -----=-----------9Q*---------------------_-Rock Size ---2-------------------------- <br /> Distance to nearest: Weli .___ ------------Foundation _.___ /!Q__"___ Prop. Line ___---;�_'/______.__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#_____________________________________________ Date __________________________________) ' <br /> Septic Tank (Specify.Requirements) ---------_ �-------------------------------------------------------------------------------------------.---------------------------- <br /> Dis' osal Field ISpecify Requirements) _____-401---I,_each..Linp-__&____ " ---------------------------------------------------- <br /> - - - ------------------- <br /> ---------------------------------------------------------------------------------------------------------------------- <br /> "� ]Draw existing and required addition on reverse side) <br /> I hereby certify that I hove'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: <br /> "I certify that in the performance of"the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed- ------------------ <br /> --- ------------ ------------- <br /> Owner <br /> BY -G------- - Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY 9y <br /> APPLICATION ACCEPTED BY J ------ ----- -------------------------------------------------------------- DATE ----------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------- ----- ---- ---- ------------------------------------------------------------------------------------------------------------------------- <br /> --------------------- ------------------------ ------ <br /> ------------------------------------------ - <br /> Final Inspection by; -- - ----- -------- - - ---- -Date -"� <br /> ---- ------------- <br /> SAN JOAQUI LOCA1 HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />