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FOR OFFICE USE: <br /> APPLICATION ,FOR SANITATION PERMIT <br /> ----_ - ..` 7 y .�^� Permit No: <br /> fCom lite in rip <br /> i licate) <br /> p p � <br /> -- ------- -----`------------------------- <br /> ., , Date Issued _ -1�=-7� I <br /> ------------------------------------------- ---------_------ This PerMINE,,' ares 1 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 /> .JOB ADDRESS/LOCATION -__�-��� �1 --- --------------------------- 'r,� CENSUS TRACT <br /> t, i <br /> �f ,? ' l Phone- <br /> Owner's Name --{".�-�-�.� �-�-��'-�' .----/ Tf-/�--�----- --- --------- ---�-------- ----- ---- <br /> �_ --------------------------------------- ---- ------------------- y ---------------------------------------- <br /> Contractor's <br /> _ <br /> Address ----- � _. Cit --- ------------------- --------------- <br /> Contractor's Name ----------------------------Licen ye # _.��� _ Phone '-.- � `l <br /> ' - _ , e ¢ d / <br /> Installation will serve: Residence rime t House Commercial Trailer Court <br /> Motel ❑Other I---I -------------------------------- - <br /> Number of living units:--- ----- Number of bedrooms Garbage Grinde _/_t/.P)Lot Size ---- <br /> PP <br /> Water Su I Y Public S stem Y and name _ ______.-------------- -------•----------------------- ---------------------"�'---`---------------------`•-_-Private �- <br /> Character of soil to a depth of 3 feet. Sand'❑ Silt� Clay E] Peat f] Sandy Loam❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Materiae -- ----- If yes,type ---------------------------- <br /> • t <br /> .(Plot plan, showing size of lot, location of system inrelation 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 /> Capacity121M----- Type�__e;4--'=�_ Material_ °--- No. Compartments ----4­.. <br /> t �� dl Pro ------------ <br /> ----------------- > <br /> Distance to nearest: Well ----��--�'_ Foundation __ p. Line __ 'E'LEACHING LINENo. of Lines _.___ �-______------- Length of each line.-- `.` Total Length - -`------------ <br /> D' Box �7 Type Filter Material __ - Depth Filter Material f��------ <br /> Distance to nearest: Well _____________�__.�`Foundation _-__ Property Line, ; <br /> ------------------- <br /> ` ` J `4 ` o <br /> SEEPAGE PIT Depth �+�_--------- Diameter � t_ Number _-__ F ______-___.______ Rock Filled Yes No i❑ <br /> Water Table Depth ----- f6----------------------- -- Rock Size -- ------- r f <br /> Distance to nearest: Well -------------------Foundation _el� ------ Prop. Line <br /> ) <br /> _%I_______- <br /> •---------------REPAIR/ADDITION(Prev. Sanitation Permit # -------------------------------------------- Date ------------ ----- <br /> Septic <br /> ----Se tic Tank (Specify Re uirements ----------- ---------------------=-- ---------------------- ------ <br /> i OW I <br /> Disposal Field .(Specify Requirements) <br /> ents) ----------------------------------------------- ------------- <br /> _'V <br /> ------------ <br /> - i ------- ---------------------------•------------------------- <br /> --------------- � -- _ <br /> -----v ------------------------------------ -------------------------------------------------------------- <br /> (Draw <br /> existing and required 1addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rues and Regulations of£the San Joaquin Local Health District. Home owner or <br /> licen-sed agents signature certifies the following-, ..,,-,, ,...{ <br /> "I certify that in the performance of 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 Owner <br /> ------- Title`` - <br /> ---------- <br /> (if <br /> ot?han owner) If t <br /> OR DEPARTMENT USE ONLY p <br /> APPLICATION ACCEPTED BY ___,e!"` ; f DAT[ I 7 <br /> BUILDING PERMIT ISSUED ------------ --------------------- <br /> ------------------ - --------------- DATE . <br /> ADDITIONALCOMMENTS -- ----------------------------------------#'---- ----------------------------------------- --------------------- ---------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------- <br /> -------------------------------- ---- ------- ------- ----------------------------------------------- --------------- ------------ --------------------- <br /> -------------------------------------------- ----------------------- ---- b ------- <br /> Final Inspection by: -----=---- -- -�---� i ------- - -------- --- ----------------------------------Date --- - ------- -- ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-''68 Rev. 5M <br />