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FOR 01=FICE USE. APPLICATION FOR SANITATION PERMIT <br /> ............ .........•-- - Permit No. ---7Z •7 Y <br /> I <br /> Com ete i <br /> n Triplicate)�67 <br /> :................................•-----........... ------ : //"j�Z Q%2 Date slued .../.- 7.77 <br /> ................................... <br /> .................. .... This PermitExplres t Ysarl:f!om Datelssue l <br /> � <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 com Iia �ce,with�Cynt C,�rdin nce 149. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 0 .�,L... �c1-�c� Q-._.C ........,.CENSUS TRACT ....................... <br /> ! Owner's Name ....... ................ ........ ......... ........__.-Phone .•.. ...... <br /> Address ...,.. City Phone ..................-.........._ <br /> d? dam-...... . ... ........ ....... ....--...._.......... Ci . .... <br /> � .. .:...3...-------.License 99t /�A�� -- <br /> Contractor's Name -.-.-. .....- i...�.� . .......- -- <br /> ' Installation will serve: Residence[Apartment House Commercial ❑Trailer Court 0 <br /> i <br /> i Motel ❑Other ................................... <br /> Number of living units:......f... Number of bedrooms ...:3.....Garbage Grinder ............ Lot Size ..... '�'•-•••- <br /> System and name .••••....... ........Water Supply: Public :........... ... r" . ' {" ......-•••-•......•• Pr1va <br /> te <br /> Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: ' Sand❑ Silt Q ' Ci y ❑ Peat 0 -Sandy Loam C3 <br /> Hardpan Q Adobe Fill Material <br /> If yep,type <br /> j [Plot pion, showing size of lot, location of system in relation to wells, buildings,-etc. -must be placed an reverse side.) <br /> N <br /> NEW INSTALLATION: (No septic tank:or seepage pit permitted if� ublic sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK lej" Size__ f. 1��'S�................... Liquid Depth..-�.r--1 <br /> ................... } <br /> I <br /> 1 <br /> Capacity -Type <br /> . <br /> Type ----••-..----- Material.----dam.^- ----...- No. Compartnients .?=............. <br /> .l.a. <br /> Distance oto nearest: Well ...........5�.1-�-.............Foundation •..- • �-•-•- p•.Line - <br /> .......... <br /> LEACHING LINE I No. of Lines ­=-Length-of� Length•-of each line-------..l- ........ Total Length <br /> --.-. -'- <br /> D' Box Type Filter Material .......Depth .Filter Material L' <br /> Y <br /> Distance to nearest; Well --.... Foundation ..... Property <br /> - Line ...... -•• -•• <br /> ..... <br /> [ } Depth .-..'- r lb"k. -..-.......I............... Rock Filled Yes Q' No Q <br /> I Water 'fable Depth ........... ....6 1-t----------k .........Rock Sixe f..,l!�(i -._-.'............ <br /> Distance to nearest: Well .........-.�o- -" Foundation .... .Prop. Line ...........•. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------•.....................-----....-••••-. Date ......... ........... <br /> Septic Tank (Specify Requirements) ..........•---------------------------•--------••...•__........_....- ............... <br /> Disposal Field (Specify Requirements) -------- it a ...'~.- �`�._ -.•... .. .-• <br /> .............. <br /> ----------------------- <br /> ------- ------------_----------- - ••------.........----._........--.............. <br /> -• ------------ --- t _. ..r <br /> ------ ------- .... <br /> (Draw exis ing and required addition on reverse side) <br /> I .hereby certify that 1 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 Local Health.011strlct. 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, I shall not employ any person lin such manner <br /> as .to become subject to Workman's Compensation laws of California." <br /> rSigned -------------•--------------- Owner <br /> �. - Jitle <br /> BY • •--....... <br /> (if other than owner). <br /> FOR D0ARTMVIT USE ONLY <br /> I APPLICATION ACCEPTED BY -- ------ <br /> ::.....,-DATE ,:�1 '�~' j .�� <br /> F BUILDING PERMIT ISSUED ---------------------- --_:: <br /> - --------. ..-DATE ---- - ------------------------ -•---- <br /> ADDITIONALCOMMENTS ----------- -----------------------•--•---•--.._..--..........----.------------------------------------ ------ --------------------=- -- ......--------------- <br /> -- -- - <br /> t - ------------------------------------..--------------- ._.. <br /> ------------••-----••-- ...._... --------------..----------•---• -- ......--•---• .......................... <br /> ( <br /> -------------------------------- . <br /> ........---..._.-- ..-- -- ----- ..-----------•----------------.- <br /> Findl Inspection by: s Y ±-4....._..--......- — '= .------ <br /> Date <br /> EH 13 24 1-68 Rev. 5) SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> 4 <br />