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'FOR OFFICE !JSE:. � � F <br /> APPCATIO'N FOR SANITATION PERMIIT <br /> --------------------- <br /> ---�----------- ------------- {Complete in Triplicate} Permit No' �7�.....••----. <br /> Date Issued 5.=f 7J__ .___. <br /> ---------------- ----------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 _10-5 ----------- -�---Imo-`-------- -- -------- CENSUS TRACT <br /> Owner's Name -------------------- Phone __�� <br /> --- - _ <br /> Address ------I�}9l oZ_�- --- ----------- "t - .�il� • ---------------- 7 <br /> Cit -- ---- <br /> '�_ l License #'�Dv �i----- Phone�_�__ . ------ <br /> Contractor's Name -- -- ._____ ___ r <br /> Installation will serve: Residence A artment House 1❑ Commercial ❑Trailer Court ;❑ <br /> k <br /> �1 p ..mss <br /> - .. ._-�,�..11l�atel..❑_Other-_------�•-�---- ------=----_--=--__`.,,� :-..,�., -/ <br /> .i "'�\ � 7�Garba 4 10--�--- -- <br /> Number of iiv�rs units:_-__ _______ Number of bedrooms ___ ___ _ ge Grinder _____,____-_ Loi Size _ - ------------------ <br /> ...� g 4 <br /> Water Supply: Public System and name --------- -------------------------- ------- i-------- # --------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand' i Silt❑ Clay ❑.. Peat �t❑��[ Sandy,Loam;?q, Clay Loam D <br /> Hardpan Q Adobe ❑ Fill Material ___.__`c�_ 1f yes, type ---------------------------- <br /> (Plot <br /> _____.______________ _____ <br /> (Plot plan, 's ! buildingst etc. must be placed on reverse side.) <br /> (Pl'ot plan, showing size of lot,�location of system in relation to wells, <br /> NEW.INSTALLATION.1 (No septidtank or seepage`pi't�permitted if public sewer is available within 200 feet,) �- <br /> PACKAGE'TREATMEN7 [ ] �,' ;[�1 I - Liquid Depth _____________ <br /> SEPTIC TANK Size <br /> Capacity - Type -------------------- Mciterial_--------------- <br /> "" ---------- - - No. Compartments <br /> .._ c __Foundation ---------------------- Pro Line ----------------- <br /> -LEACHING <br /> --------------- � <br /> stand o:nearest: Well --------------------- ------------ p <br /> —LEACHING LINE [ ] N6. 6f Lines ------__--------------- Length of each line---------------------------- Total Length -------------------------- - <br /> 'D' Box __J___,,T_ype Filter Material ____________________Depth Filter Material ---------------------------.--------------.- <br /> Distance to nearest: Well____----------------- Foundation -------- -------------- Property Line -----------------_----- <br /> E <br /> - <br /> —SEEPAGE PIT. ].`. p -Diamefier Reck,Filled,�Yes.O�.NorG <br /> ` Water Table Depth f - ` -Roc Size -------------------------------- <br /> i <br /> Distance to nearest. _______ _____________ -Foundation - Prop. Line ..._____________....-- <br /> t ------- ----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# �--- ---------------------------- Date F_________ •-----------------------j <br /> Septic Tank (Specify Requirements) ------------- � - -- - -� <br /> - • <br /> Disposal Field (Specify Requirements} ---------__ ,�y� --- <br /> t --------------------------------------- ----------- <br /> k ------------------------------- -- ------------------ ----- ---- <br /> ---------------------------------------------------- ' existing k <br /> -- <br /> ------------------------------------------------------- --------------- ---------------------- <br /> (brow <br /> a`nd required addition on reverse side) <br /> i I hereby certify. that .I. have prepared this application and that the work will be done in accordance with San Joaquin <br /> ,--•-�---County-Ordinances;±Sfate Laws,-.andJRules and Reg ulation_s_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.1the�work for which &s permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's tComi3ensation-la!�sp ft California." <br /> SigneSigned ---- -------- ----- ---- --- - - Owner <br /> d ---------- -------- - -------- - <br /> (If o e than owner) r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -------- ----- ------------------------------------------------------- <br /> DATE -------------- <br /> BUILDING PERMIT ISSUED -------------------------- ------- <br /> -------DATE ------------------------------------------- <br /> - <br /> �-ADDITIONAL COMMENTS -------------------------------------------------------------- ------------------ --------------------------------- -------------------- -------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- <br /> -------- ------ -- <br /> - <br /> -------------------------------------- ---- - <br /> Final Inspection by: ---- - ----- 1-+�-- ------------------------------- ---------------------- ---- ----- ---- <br /> --------Date ���- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />