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FOR OFFICE USE; �. . � <br /> a �'��� APPLICATION FOR SANITATION PERMIT 3Q 6 <br /> ...... . , . Permit No. ._... ... <br /> ' <br /> (Complete in Triplicate) <br /> 4 <br /> Date Issued . <br />. This Permit Expires 1 Year from Date Issued 5. 7:7S <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 incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> �.. ..`' .. <br /> JOB ADDRESS/LOC TION .;/� <br /> . . . ...... ...... ............. ...................CENSUS TRACT ......................---- <br /> .. <br /> Owner's Nam ... ..�yl,<,,--- -- -_............................................:................Phone ................................ <br /> ._.. <br /> Address . ................... .............. ... ity ... <br /> ......... .............................•----...................••---...... <br /> Contractor's Name .... .... :.. . . .....------. license 1.3,31Z. Phone <br /> Installation will serve: Residence partment House f] Commercial QTrailer Court 0 <br /> Motel [IOther .........-•------ 2 GeV oot"s <br /> Number of living units--_-------- Number of bedrooms ..3......Garbage Grinder .....I...... Lot Size ....�.. .___ ... ..... .. .......... <br /> Water Supply: Public System and name ...:...... ........................................-•--------..............................._................Private Q <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat Q Sandy Loam❑ Clay loam ❑ <br /> Har"dpan p Adobe 0 Fill Material ............ If yes,type <br /> 1PIot 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 I ] Size.....{-- -�� ....................... Liquid Depth ..................• <br /> Copocity -1 X(P.6). Type 4f eh ------- Material------------------A-- No. Compartments ....;&.......... <br /> ' Distance.to nearest: Well ..../- ....................Foundation ----tc...:..... Prop. Line ..&za...... <br /> LEACHING LINE [ ] No. of Lines .... ------ Length of each line...../.Q..,0•........__I Total Length ...........................•to <br /> 'D' Box .........ILL Type f=ilter Material ....................Depth .Filter Material .............................I.............. U <br /> Dist once to ne est: Well ........................ Foundation .................... Property Line ....................... n <br /> %` }iometer plumber-. Rock Filled Yes No iLj <br /> SEEPAGE PIT [ j Depth ,/--d( -• /A ............. , ❑ <br /> Water Table Depth ... ---------•-- -•-••-------------- ..........Rock Size ... -- --- <br /> Distance to nearest: Well ........................................Foundation ......_..... ....... Prop. Line ......................p. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......•..._....-• � <br /> .......................... Date .-----------.................... .) -� <br /> Septic Tank (Specify Requirements) ............ <br /> Disposal Field (Specify Requirements) ---------_--_- -------- ...................•-...------------------------.....................---------_-- ..................... <br /> :i ................. <br /> -i .............. <br /> -------------------...... --------------------------------------------..------------------------............-.................................................. <br /> I {Draw existing and required 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 Joaclaln <br /> Joaquin Local Health:District. Nonce owner or licett- <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joa q <br /> 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 sulhiect Workman's Camp so on laws of California." <br /> Signed ... <br /> Owner <br /> By ---------- ------------------------------- Title ---•------ ---------------------------•----- ••----..-.-------....... <br /> (If other than owner) <br /> DEPARYMPIT USE ONLY <br /> APPLICATION ACCEPTED BY .. •..................... DATE _. - ..-..7S.............. <br /> BUILDING PERMIT ISSUED ------------------•---......-...- - •-•-... .-------------- DATE <br /> ADDITIONAL COMMENTS ----------•-•...----..-------------...................................... •-------•---------- ---------..--------------------------------------.-------........ <br /> . <br /> ----------------------------------------- ---_------------------- --------------------------------___--------------------------------------------------------------- •---------------------- . <br /> --------------- ---------­---- ---.......- ----- --------------------- - -- -�• ...................... �`�-- <br /> - --------------------- -------- ........ ... .. . . <br /> FinalInspection by: ....... ........... . -- ---- --- - . ---- .-......_............................................ Date .�. !''.. .............. <br /> Ell 13 2L 1-68 Rev. 5H SAN JOAQUI LOCAL HEALTH DISTRICT 8/7a 3M r <br /> v/ <br />