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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> _.... Permit No?S.` <k - . <br /> ................. ................. <br /> (Complete in Triplicate) <br /> ._....._...................................... This Permit Expires t Year From Onto Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install ihe,work herein <br /> described. This application is made in compliance with County Ordinayls No. 549 and existing Rules and Regulations: <br /> X <br /> JOB ADDRESS/LO�T .mv <br /> #ON ........5.. ...7_.�� '...... . ....... ......................CENSUS TRACT ..........,.......... <br /> ...... <br /> '�' Pho x.31 ...af.� ...... t <br /> Owners Name 1�. ...y..b.r.... 1�-Z.lx ..................... ne-� �. <br /> Address..5- .TS . h e,) o .o��Q..... ..._. . � ..............................City .��Q.G�*T -W......_.•..........._..........,...... <br /> _._. <br /> Contractor's Name ....License# ......... .............. Phone 401".-- 7 <br /> ..._. .................................................... . <br /> installation will serve: Residence Apartment House Commercial ❑;railer Court C) <br /> ,� i <br /> Motel Q Other .................I......................... �+ <br /> Number of living units:... ........ Number of bedrooms .Garbo a Grinder Lot Size <br /> Water Supply: Public System and name .......................................................Private ❑ ' <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam 0 Clay Loam <br /> F ' <br /> Hardpan❑ Adobe❑ Fill Material ............ If Yes,type............•.. ..•......... J. <br /> iPlot 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 /> Size__. Zx..q_I- •�r~..�.._...... Liquid Depth ?... <br /> PACKAGE TREATMENT l ] SEPTIC TANK f ] - <br /> Ca <br /> Capacity / 0.. T .-.(�`Material.- "!'`!�i . No. Compartments <br /> ..................... <br /> P tY •-- Type 1 r <br /> I b `il..._. Prop. line ................. .� <br /> Distance to nearest: Well __ �..----` ..-----•..•••_Foundation .............. ,g�g <br /> LEACHING LINE No. of Lines 9.... __.._ Length of each tin - --- - A0O?_--- Total Length .--,�iG9�!.• •..-- W <br /> D' Box .--.-�..._ Type Filter Material`J•�°1``.....Depth Filter Materia# .f..z..`.. __... .. ... ....�....... <br /> Distance to nearest: Well .. - .... Foundation ....... ......... Property Line —..._.--- <br /> - f y <br /> �0 . ... ........ <br /> SEEPAGE PIT Depth ­,25........... Diometer ...... Number ..._.r!..................... Rode Filled Yes,$ No ❑ <br /> 1 ..... <br /> ff .:. ._R <br /> . ock Size -------------------------------- <br /> Water Table Depth ...................�f?-�---- foundation ... <br /> j � <br /> . <br /> -Distance to nearest:,Well _�D6_. :.�....._... ...r'>.._........ Prop. Lina...............k; <br /> l <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-r....................­­ ------ Date .. ._..______......__.....------•). <br /> Septic 7ank'SSpecify Requirements} ..................._..-----..._-- ...............; ..,. ....� ...,....... <br /> _...._.. ........ <br /> 1 <br /> Disposal Field (Specify Requirements} .........................................t.......................................--•.................................---•...._...... <br /> r.4 <br /> • __•.......•...................................•-----_-...._.._..._...--_•--....._-.._--•------------•-..-•._- :...-__.... .............• ........................................ <br /> ................. <br /> ......... <br /> It ' ...-- �-- (Draw existing and required addition on-reverse side] <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Jotsquln <br /> County Ordinances, State Laws, and Rules and'Regulations of the San Joaquin local Health.Dislrld.Heine owner e► liven• <br /> sed agents signature certifies the following: <br /> "i certify chat in the performance-of,the work for'which this permit is issued, I shall not employ any person In such manner <br /> as to becom subject to Workrr�an's Comp ns tion favus of California." <br /> Signed .... Owner <br /> By............. ................................... Title ..............................- <br /> ................ <br /> (If other than owner) <br /> EPARTMENT SE ONLY <br /> l APPLICATION ACCEPTED BY .... pp- <br /> r ... .. ...:.......•------• -._,............DATE ._::....,_....._(!..-...;7. ..::.:----• <br /> _<: - - - . .... .. ........DATE .... <br /> BUILDING PERMIT ISSUED ..........._._ f_. ._._.....: <br /> ADDITIONAL COMMENTS---.. <br /> 1 <br /> l ......... ......................... ......... ......................_...._..... <br /> S <br /> ...... <br /> -------------------- /. <br /> .............................. ... ....... ... . .. .................. ••-•----------................------............. ... ._ ----- ........ <br /> Final Inspection by: .... ..............Date ... .... ..f-. ...�.. ...... <br /> IIi 13 24 1-68 Rev. 5M SAN JOA N tOCAL HEALTH DISTRICT 8/7h 3M <br />