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FOR�OFFICE'I USE S <br /> �- .; _� - _� APPLICATION FOR SANITATION PERMIT <br /> --------- / i Permit No. <br /> (Complete in Triplicate) <br /> -------- =--- -- <br /> _--i----------------------- This Permit Expires I Year From Date Issued <br /> Date Issued ----- <br /> O�S� z�Q-c�S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. Thislapplicat.ion is ad in compliance with ounty Ordinance No. 549 and existing Rules and Regulations: <br /> s (� ,f o <br /> JOB ADDRESS/LOCAT N.f__ "______ __-- _-__ __ . __ � --____'._ CENSUS TRACT _ <br /> - - y <br /> Owners Name --- 6 Phone S l <br /> l ---------------- - - -� ----- - -6- , s <br /> Address " i! F - - <br /> r;_. _ .�= ( <br /> Contractor's Name ------------------------ -- --��- - �1 -----=-------License# �-�-I-��Y;---- Phone Y��-4, 0,7----- <br /> } Installation will serve: _r'Kkesidence (� Apartment House❑ Commercial :❑Trailer Court ',❑ <br /> t•- Motell F1Other - --------— <br /> Number of living units:---!------- Numbet of`�bedrooms _____Garbage Grinder ------------ lot Size ____-___________-___--- <br /> Water Supply: Public System and name --------- ---------------------------------------------------------------- ------Private <br /> i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan N Adobe Fill Material ---- ------- If yes,type ------_____________________ <br /> t - ' <br /> (Plot plan, showing size of lot, location of <br /> system in relation to wells, buildings, etc. must be placed on reverse side., <br /> i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sever is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK' Size ------------- Liquid Depth __ --------- <br /> Capacity -_�r _ :__i -- Type v� 'yMaterial__ '_ _ No. Compartments --------------------- <br /> Distance to nearest: Well ---------------..Foundation `------ Prop. Line ____„r__/_ -_-_-._{ <br /> I LEACHING LINE No. of Lines -------------------- Length oZr­k <br /> ac line---.--�- _____________ Total Length _____f�I)__.....__._... <br /> I e� <br /> ' L,-"Type �� - - De )Material -------- ,��----•---D' Box'.____ Filter MaterialDepth Filter , <br /> r � <br /> Distance to nearest: Well _ _r�, __.__ ------ Foundation _.___ /$_ --rt'_____ Property Line --�-_'�`____._.__: � <br /> - Diameter r Number ______________�- -__.__ Rock Filled Yes �J No I� <br /> SEEPAGE PITA Depth ___ - ._.. - -.---. <br /> 11 <br /> P ----------------- x% ��1/1��------- <br /> Distance <br /> u�1-Water Table Depth ____ -- ------------ ---------Rock Size _ �- ____-- -- ' <br /> Distance to nearest: Well ------/-672_._f':----------------Foundation 10-7t7 ____ Prop. Line .. ------ <br /> REPAIR./ADDITION(Prev._Sanitation Permit x# -------------------------------------------- Date ----------------------------------) � <br /> SepticTank ,5peci#y_Requirements) ----- ------------ --------------------------------------------------------------•--------------------------------------------------------- <br /> Disposal Field (Silecify Requirements)ments) <br /> ----------------------------••------------------------------------------------------------- <br /> ------------------------------------------ <br /> ' --________________-___----_-_--_.-__________________________________________.____________________________.______-_____-____ <br /> ____________________.________ ---__________ _F_______-______________ <br /> -------------------------- ---------------------------------- <br /> - -- - <br /> -----�-= (.`Draw existing and required addition on reverse side) <br /> I hereby certify that I have preparedthis 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's'ignk 3dOur"e"certifie3 the.following: <br /> "I certify that in the pe-rformance4f_:tlhe work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Com pen sation� laws of California." <br /> Signed ---- ----------------- --- ------- ---- r ----- ---------------- - Owner <br /> BY ----------------- ----- - -`---- ----------------------------- - itle .---- ---------------------- ------------------ ---------- --- <br /> (If o er th n caned <br /> T F R DEPARTMEN USE ONLY <br /> APPLICATION ACCEPTED BYE_.__ _� a �� DATE _.4 -�Y17 �______________ <br /> a-- -------- ----------- ---------------- ------------------ <br /> BUILDING PERMIT ISSUED ------------- `-------- -------------- ----------------------------------------------------------DATE -----------------------•------------------- <br /> ADDITIONAL COMMENTS ------- 4-T <br /> ------ -4 <br /> 74j•. � '----------------------------- --------------------------- <br /> ---------- - ------ ------------------------------ r-7 ----- ----- ------------------------------------------------------------- -------------------------------------------------- <br /> -------------- <br /> Final Inspection bY- --------- 1�--'-- - -------------------------------- ------ <br /> IDate <br /> SAN JOAQ N LOCAL.. HP,LTH„DISTRICT <br /> t E. H. 9 1-'6$ Rev. 5M <br />