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a FOR OFF.iCE USE: <br /> • ... ICE....................... APPLICATION FOR SANITATION PERMIT <br /> ............. ...... ......................... ... q <br /> ((Complete in Triplicate) Permit No: .-7 5/-0'0............... <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued .1--.: _ZV <br /> Application is hereby made to the!Son 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,*sting Rules and Regulations: <br /> I <br /> JOB ADDRrESS"/LO.CATJON-_.a.__.te. 1 <br /> ' .. o/ 7 .G../.. <br /> .CENSUS TRACT��' � <br /> .. <br /> Owner's Name �.2 <br /> Address X 7 U.. t F # city <br /> Contractor's Name ..............•-----_----------------- - License# ------- - ----- Phone ._............ ............... <br /> Installation will serve: Residence Apartment House fl 1ommercial: Trailer Court <br /> Motel ❑Other-� r - _ " . !-- -------- <br /> Number lof living units:......__ Number of bedrooms _ ..._....Garbage Grinder ._.__.._ Lot Size .............................. <br /> - - -=-- ------ <br /> Water Supply: Public System andct__- - - -..... - - ------------------ ........ ...........` ..._....... Private <br />•' ^CITd�a�f soil to a depfh'of 3 feet: Sand It❑ Clay ❑ Peat❑ Sandy Loam•❑ Clay Loam I-] f <br /> Hardp;n ❑ Adobe E] Fill Mcterittl ............ If yes,type............._.._..._..... - <br /> i A <br /> (Plot plan, showing size of .lot; location`of Wsfer In latian �o wellt, buildi gs, otc, must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is ovailabltl within 200 feet,] <br /> i <br /> PACKAGE TREATMENT [ I SEPTIC TANK i ) Size............................. ................. Liquid Depth -_........................ <br /> `__AI <br /> �CaPacity , ..;. Type A_...'.. ........ M`aterial----------- ---------- No. Compartments ---........ <br /> 1 Distance toeUrest: Well -.. � ..._....1........ .Foundation ........ ............. Prop. line ........... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of eaih line...........f.........._._ _ Total Length .................. <br /> 'D' Box ..i........ Type Filter Material ---------I........t[Depth 'Filter Material ............................................ <br /> Distance to nearest: Well ........................ Founddtion ...t..........1....... Property Line ....................... <br /> SEEPAGE PIT Depth ...............-Diameter ................ Number .......1......... ........ Rock Filled Yes ❑ No ,10 <br /> Water Table Depth ---- ..........................................Rock Size ................................ <br /> Distance tb nearest: Well _.__....................................Found6tion ....._._...... ..... Prop. Line ........._........... <br /> 1 7 <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------------------------------------------- D to _ _.._-_........... ._ . . .) <br /> I _. f / <br /> Septic Tank (Specify Requirements) ----- .. s1...-...11(_401e.. . ..... .. . ...n.. .. <br /> - - <br /> Disposal Field (Specify Requirements) f A- -------------- ------------------ ---- ----- ........... ------.. ......---•------ --- <br /> - lt��•ill,... IJ.:: <br /> ......................................................................................................... ' .... <br /> _.__ ...�............I <br />• (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will � done. inraccordancl�vvith San Joaquin <br /> He <br /> County Ordinances, State Laws, and Rules and Regulations of the San Jolaquin Local alth District.-1116" owner or licen- <br /> sed agents signature certifies the following: <br /> "1certify th the performa a the work or which this permit is issued, 1 shall not employ any person in such manner <br /> as to bee e s b]ect to rki Compe tion laws of California." <br /> Signed _. . .........l <br /> ..... _.. . .<.. . . .... ... . .. -- -------------------- Owner f <br /> By ............ .... - - - -------------------- --------- _ __ ........ ..... Title ......... ............................ --_---- ............... <br /> (If other than owner) ) <br /> FOR DEPARTMENT USE=ONL, <br /> t <br /> APPLICATION ACCEPTED B_Y_ I. ....._. ...%...... --...................................... - ......... .......... DATE ... ... ' ---------- <br /> BUILDING PERMIT ISSUtl)r------------- t -y_._J�- <br /> ............................................DATE -------- ....................-............. <br /> ADDITIONAL COMMENTS ............_.... ................--------....----_..................................... --------------- ---------......--------_-• . <br /> ---------------.. ...---. ------....... . ----- --- ------------------...------........................------------ .................................- -------------------------------- .....-- <br /> -- . .---­------------ ... . ..... .. .....---------------------------............--............. -----------------------------......----................... -- ... ....._.... ........ <br /> ..........................---- -------...... ------------------------------------------------------------- <br /> Final Inspection by: . - --------------------------------------...---...---.....Date ... 7 - <br />• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s E.H. 9 1-'68 Rev. 5M �% ,. <br />