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! FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Phrmit N�- --72-- -------------- <br /> ---------------- --------------- --------:-------- <br /> ------------.---------------- ----------------___..---___----__-____ This Permit Expires i Year From bate Issued <br /> Date Issued - - _ <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 in compliance with County Ordinance No. 549 and existing Rules and Regulations:. <br /> a <br /> B ADDRESS/LOC CENSUS TRACT ------------ <br /> "ATION ._--.---.__�_ o.-�� <br /> Yv�.rv.� <br /> Owner's Name z Phone <br /> - <br /> Address -- _ f ---------. Cit <br /> Contractor's Name -- -----.License # ------------------------ Phone ------------------------ <br /> Installation will serve: ResidenceXApartment House❑ Commercial :❑Trailer Court <br /> 1 Motel ❑ Other --- (� <br /> Number of living units------- Number of bedrooms -J--_ __Garbage Grinder ------------ Lot Size -----n9_•_2_x_ ----- ---- <br /> Water Supply: Public System and name -_COWS---•- .JPrivate F1--------------------------------------------------------- <br /> Character of soil to a depth of 3 feet, Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ClayL Loam:❑ j <br /> 1 Hardpan ❑ Adobe K Fill Material ------------ If yes, type ---------------------------- <br /> (Plot 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;[ ] Size-SX1O__K__�- ------ Liquid Depth ---------!-' <br /> Capacity _ - _ -__ Type -- _ P` Material_ __.__ No. Compartments o2'1 -.........__ <br /> Distance � �� <br /> nearest: Well ----ti)n----------------------Foundati n --- ----------- Prop. Line -� --------------- <br /> LEACHING <br /> - •--____--LEACHING LINE HI No, of Lines -d--------------------- Length of each I- e.-._$5-_- ----- Total Length VIP--__---_-_---_ _ <br /> ' E <br /> D' Box --- �--- Type Filter Material --------Depth Filter Material ------8------------------------------- <br /> 'D' <br /> ---------- •----------•----- l <br /> I . <br /> Distance to nearest: Well A-------------- Foundation ---_--------..--------_ Property Line --__--------_-_-_---_-__ <br /> y SEEPAGE PIT [vill Depth r� <br /> p _�-.---______- Diameter �_-_--_--__ Number _s-'-�---------- ---------- Rock Filled Yes; No i❑ i <br /> Water Table Depth _-6 ---- <br /> p Rack Size _ <br /> Distance to nearest: Well — ----------------------------Foundation I:P� _f-------- Prop. Line -- -._.--__----__- <br /> REPAIR ADDITION <br /> � (Prev. Sanftationi Permit# -------- ------------------------------------ Date ---------------------------------- <br /> Septic <br /> - -•----------•--------------Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- - <br /> 1 <br /> Disposal Field (Specify.. Requirements) ------------- <br /> . <br /> --------- - -- ---------- --------- <br /> -------------------- - --- „ <br /> __ <br /> J(Draw existing and required addition on reverse side) 4 ` <br /> I hereby certify that I have preparred this applicationand 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-signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner i <br /> as to becom sul�.le <br /> Signedt to Workman'si,Compen ation laws-of California." <br /> 1 <br /> -------- Owner d <br /> By ---------------------------------------------------- -------------------------------------- ---------- Title --------------- W :„ <br /> If other than owner)i <br /> FOR DEPARTMENT USE ONLY 4 <br /> 'i <br /> APPLICATION ACCEPTED BY ------------ DATE ------ <br /> BUILDING PERMIT ISSUED -- --- -- 1------------ ----------------------------------------------------- -------------<k°°"--.---DATE S <br /> ADDITIONAL OMMEN S ------------ - l <br /> j$ ).. <br /> ----- ---- ---- --- ------ ,- - = w_�:_ - _ _ - _„ ;�.-- <br /> ----- ------ - ----� ,---- :: -- - -- ------------ -- ' <br /> --- <br /> Final Inspection by: Ii <br /> D.to f����---- <br /> - f <br /> SAN JOAQUIN LOCA_ HEALTH DISTRICTAk <br /> E. H. 9 1-'6$ Rev. 5M '`._ .-�•� ti 7 X <br />