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FOR OFFICE USE: APPLICAtiON FOR SANITATION PERMIT <br /> .---......lG<3o - <br /> ............ <br /> (Complete in Tripllcate) Permit No. ..� '.` . <br /> Date Issued .,......._{:5.. 1 <br />................ <br /> ...............................-....-.. This Permit Expires 1 Year From Date Issued � f <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 /> y <br /> JOB ADDRESS/LOCATION .........( -1.7..... `]F',j 7ac!e.6 .....................................CENSUS TRACT <br /> Owner's Name .. Phone .q.77. ��'3 - <br /> Address City - ............. <br /> ..:.. ....:........:....:....:...:.. --------------- . .. .. .... . <br /> Contractor's Name '►�..._.�..���-t S fif �Sa!!`� ---_.......License ..... Phone <br /> t <br /> Installation will serve: Residence [ Apartment House❑ Commercial ❑Trailer Court ] <br /> Motel C]Other ......... <br /> .......:..:.:..: <br /> Number of living units:.....fi.-.--- Number of bedrooms _3......Garbage Grinder ..... --.. Lot Size ...(- .x.U.z.................. <br /> Water Supply: Public System and name .... )d1.__... ........-----.......------------------------------------------------------------Private ❑: <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan [] Adobe,[A Fill Material..........:Af yes,type ,.....................................:... f.J <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 j ] SEPTIC TAN K Size........! acC ,. . .. .......I—....... Liquid Depth ...-�.�..� ^....... <br /> �f1J <br /> Capacity ...j�.r� .--]-- Type .1.1r .t osd�.!Material.__-• ._-cr No. Compartments .... ............. <br /> Distance to nearest: Well _6,12c'--------------Foundation JO............ Prop. Line .7................. <br /> LEACHING LINE [ ] No. of Lines —7(�7f'507.6w..... Length of each ke.............................. Total Length <br /> 'D' Box ...!-------- Type'Filter-Materia# � . .... .. epth� Filter Material .--02..................................... <br /> Distance to nearest: Well ....f:a.m.........-.. Foundation ............ Property Line ....... <br /> PIT [ ) Depth ..-10Diameter . .... Number ....._r.................. Rock Filled Yeses No Q- <br /> Water Table Depth ........Z..... •.. ........:..............Rock Size ... r -- .._.. <br /> Distance to nearest: Well ............JP_A ................Foundation ... .......... Prop. Line ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit!# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) I. _ ... .......... ------------------- ....... ...........-------._................. <br /> r <br /> Disposal Field (Specify Requirements) .................. <br /> ` <br /> r <br /> : ...... ......................................................•------•---• ........__.......................--------- <br /> t <br /> .............................................................. -. -. -. - ...... -------------. ..... ...................... <br /> ................--.--.---.............--...------..----.....--...._...................._•-•----__----....._---------•-•-----•---•-----•---------------------•' <br /> (Draw existing and required addition on reverse side) ' <br /> 1 hereby certify that I have prepared this 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 Caul' Health'District. Home owner or liven <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 <br /> as to become subject toJWoran's Compensation laws of California." <br /> Signed .. - -- . .. .. ........... ...........• ...-------- Owner8Y • F .. EEti.e ... ......... . - .-.-.--............................ <br /> (if other than owner) t <br /> R DEPARTNT USE ONLY <br /> APPLICATION ACCEPTED BY ..., ,. ..: :.....................r..4'...... DATE .....�Q 7�..... <br /> BUILDING PERMIT ISSUED .........------------..................................... .... . •--•= .............DATE ........................................... <br /> ADDITIONAL COMMENTS <br /> .. . .-................................. <br /> ..................-..�........................................................: . <br /> ...........-.-............ <br /> .... ..... .._..-- • <br /> ................................. /1•-- ---• ---....................................................--...... <br /> ............................. /...... --------- -- . <br /> Final Inspection by: ..........................._,:Date - ..... <br /> SAN <br /> i. <br /> JOAQUIN LOCAL HEALTH'DISTRICT <br /> E. H.13 24 1.'68 Rev. 5M 7/723M 1 i <br />