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FOR OFFICE USE: rfi <br /> APPLICATIO1 FOR SANITATION PERMIT <br /> ----- ----------^--------------- - (Complete in Triplicate) Permit No. <br /> ---------------------------------------------------------- <br /> "" - '~This-Permit Date Issued _��2 .7 <br /> ---------- "fxpires lEYear•Frotn Date Issued <br /> ------------------ <br /> ,.'"•may <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 maddeeiir compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC N .__ ` � 'r�a4t�44_1 �����'---------------------CENSUS TRACT --------------.. _------- <br /> Owner's Name � "'-�`� - -----------Phone <br /> Address ------Xy - ----- C <br /> Cit - --------------------------------------------------------- <br /> Contractor's Name ___-___.____ --------------I_ .L,icense # --------- -------------- Phone __________________ <br /> Installation will serve: Resrcl nce ❑ Apartment House❑ Comm ial ❑Trailer Court <br /> f "tote! Other ------------ <br /> Number <br /> ► _ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---------------------------------------14, <br /> -- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private,[] <br /> f <br /> Character of soil to a depth of 3 feet: Sand'(rSilt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom-[:] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -------------------_________ <br />'4 (Plot plan)Ashoowin g size of Eat, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) <br /> I NEW INSTALLATIQN: (No septic tank or seepa e Pit permitted if public sewer is available within 200 feet, <br /> k. PACKAGE TREATMENT Z . SEPTIC TANK'[ Size____________________ ____ Liquid Depth ____________ ............ � <br /> P Y` T Yp e& _ Materia d' _:No:Compartments�' <br /> Caacit ....:..-. S <br /> Distance to nearest. Well __--&6t> -----------------Found tion _____________________ Prop. Line�O.--.- :......__ <br /> LEACHING LINT= [ ] No. of Lines r___________.__ Length of each line_j�__(__--------------- Total Length ._____..___-___.__.____._-- - <br /> D Box -- . "Type Flte�ly7latenal/` - f_� _ Ci-epth Filter Material --__--___/-�---— <br /> In <br /> Distance to nearest: Well ► ---------------- Foundation ------------------------ Property Line ____________ _________ <br /> SEEPAGE PIT [ } e pth -----:� __ r�Aete __ _._.___._.__.Number __________________________ Rock Filled Yes ❑ No .C] <br /> ter Table' Depth -------------------- - R Rock SizeIt s <br /> I _ Na <br /> Fou <br /> iREPAIRfADDITION[Prev.'Sanitationtance �negrest: We11 _____ __ _•____________________Datendation Prop. Line ..._....._..........__ �b <br /> Permit# ....-_... N.'- -11-- ------- - ] l <br /> j <br /> Septic Tank (Specify Requirernents) ------------ _4K---LN-I- <br /> :-- -��e-- ------------ t, <br /> ,; -------�-------------------------- <br /> 516- <br /> Disposal Field [Specify Requirements] . -------------- -------- ------------- - <br /> -- ------- ----------------------------------- ------------------------------------ <br /> --------------------------- ------------.- --------- --------------------------------------- --------------------------------------------- ----- 1 <br /> (Draw existing and requiF9d additionoK on-rereverse side) <br /> 1 hereby certify''tthat I ha * prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, StateLaws, 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 in!Fre performance of the work for which this permit is issued,,) shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - Owner <br /> ------ ----- <br /> By - " - ---- Title- l- <br /> - ------------------- <br /> - ---------------- <br /> (if tha owner) <br /> ORDEPARTMENT USE ONLY <br /> ---------------------------------------------- DATE -----�--14;_1__ -4 ------•--- <br /> j <br /> APPLICATION ACCEPTED�BY _______ __________ _____ ________________ �.- <br /> k BUILDING PERMIT ISSUED ------------------------------------------------------ --DATE --------------------------------- <br /> ADDITIONALCOMMENTd----.----------------------------------------------------------•-------------------------- ------------------------------------------------- --------- <br /> '--!-----------k----------------------- -------------•• -! ---------------------------------------------------------- <br /> ---------------------- ------------------------------------------------- <br />, --------- --- --- ------------------------------------------------------------------------------------------------------------------V44----------------------------------------------------I <br /> " =-------- ,- - - -------- <br /> ---------------------------- ---------- --------- - __ _ <br /> 4 <br /> Final Inspection bY� ------------------- --- -�-- --- -----------------.Date ----�---f_4- �Y.�-------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />