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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r <br /> --------------------------------------------------------- Permit No. � �__. <br /> `; (Complete in Triplicate) <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the::San,Joaquih16edt Vealth-Distrtm--for, a, permit ,tol..construct and install the work herein <br /> described. This applicatibii is_rn6rle in-cotnpliae"With County Ordinance-No..5.4Qr and_existing Rules and Regulations: <br /> _ - CENSUS Ti <br /> JOB ADDRESS/LOCATI N X531_ - �__ ` �J ------------I --------------���------ J" <br /> - ACT .----------L.�_._-... <br /> Owner's Name -------- � --- ---- - ------- ---------------- -------------Phe ------------------------ ------ <br /> Address -- 1 -------------- ----------------------------------------- Y <br /> Cit E,�_C : <br /> L _ . <br /> l�l� <br /> Contractor's Name ------------------------------------- - -------- ---------------------------•-------`:.License # ----------------------- Phane -------------------•------•--- <br /> Installation will serve: Residence artment House Commercial,: Frailer Court <br /> C] fl <br /> Motel F1 Other ---------------------­­­-------I-------- - <br /> -- ----- - ---------•--•----•----•--,-. <br /> ------- Lot Size 1�}---- ---------- <br /> Water <br /> --- <br /> Number of living units:___ ___--._- Number of bedrooms _ Garbage Grinder- _ ; �; � _ -- <br /> Water Supply; Public System and name ------------------------ ---------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sd'� S Clay E) Peat Sandy Loam 0 Clay Loam, <br /> Hard an Adobe'❑ .,Fill Slti7[aterial If yes,type ----_ -='i-r--------------- <br /> (Plot plan, showing size of lot, location of system in relaton to wells, buildings, a c,.,�p,ust be` placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank c r seepage pit permitted if public sewer is ay fl.16ble within 200 feet,j <br /> PACKAGE TREATMENTTAN SEPTIC ' <br /> [ ] [ ] Size.- ,='-- ------ Liquid Depth -------------------------- CA <br /> Capacity -'-----.,,Type s ----- _'.o. Compartments --- ---------- ....... <br /> Iti <br /> ------- -,- -�, --'.-------------------MaterialFoundafiian =--`"=N <br /> Distance_to nea eel'Well _____________ Prop. Line ------------ <br /> LEACHING <br /> -___-__--LEACHING LINE {" ] No. of.Lines "'__ - _–Q-ro�x- =.'Length of each line--_---_- i-ngth .___-______•________________ <br /> -r'___, Total Le <br /> 'D' Box ------------ ype Filter Material ____________________Depth Filte Material ,_____;f--____. <br /> Distance to near st: Well ------------------------ Foundation _ _�- - ,�__--_ Property Line .-__-_-_. ------,_----- <br /> SEEPAGE PIT Depth -_ Diameter _-__-_--_-__ Number --___-i___ ___---_-__- Rock Filled Yes 0 No <br /> Water Table - -: <br /> ---------------------------------------=--------Rock Size - ---------------------------'- <br /> w �. <br /> Distance to nea a t: Well ------------ - Foundatio Pro` Line .............: <br /> -------------- �.. <br /> p <br /> REPAIR/ADDITIONIPrev. Sanitation Per t•# -----------11-------------------------------- Date <br /> . <br /> 01 <br /> + -._-----_-__. -:-.---,- <br /> -------_-_-.- <br /> - -___--- TSe tic rank (Specify Re uirements} ------ � d - ........ _ - ..J:�--_i <br /> T-.C�tIP-------- <br /> Disposal lFie <br /> _-_-_DisposalField .-Requirements) 0- -- n- 1---mi-N-�---- _-- ----W-!-� -�-- fZO -"�----- <br /> I <br /> cG_t_ ...._...�ror -mac rr_ <br /> ------O-N E---- �------•1-�------------------------------ - -------- ----------------------------------------------------- ------------------ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and th,'at the work will be done-in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations ofi`the. Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify t i the perform cEof e work r which his permit is,'issued, I shall not employ any person in such manner <br /> as to bbject to Wor ampen tion la ' of Califf ornia Sign d -- -- -- ---•--- -------- ----- c '; Owner <br /> By ------------------------------------------- -------- --•--------------------- `Tt1i_ Title --------------------------------- <br /> -------------------------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------I_f_ =O-____--'--- DATE ------- --"1�=---�0.__r <br /> BUILDING PERMIT ISSUED__"__-_ =--= -=--==--===------- -_: --------- --------- - ---- - ---- --- ---- -DATE:.= = ___ -------- <br /> ADDITIONAL COMMENTS --- - _- <br /> Y_ <br /> ------------------- ------------ --- --- ----- <br /> - - --------------- -----...._..---------------- -- --------- --•--- <br /> ------------- --- -------- ---- --- - - -. -. ------------- ----------- <br /> - ---- - ----------- --- - --- ---------- ------- -- ---- - -- <br /> ----------------------- <br /> ------ -- --- <br /> -- -- ------- ------ ----- -- ------ - - <br /> -- <br /> Finallns - 4 <br /> - ---- -------- ---- ------- ---- --------------------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT rt <br /> E, H. 9 1- �i$•.itev 5M <br />