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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .......................................... Permit No. ...7 <br /> (Complete In Triplicate) . <br /> = a a <br /> Permit Expires t Year from Dal*Issued: . - D� <br /> Issued t. <br /> s............................ .. .. ....... ' <br /> Appikation is hereby made to the San Joaquin Local Health'District for a permit to,cottstruct acid Install the work herein <br /> described 'This application is rinade in compliance with;County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 <br /> 306 ADDRl:SSIIDCATIO :. LT ..................... <br /> .:.. CENSUS TRACTf "� <br /> F e . ... ... .Phone ...... <br /> Dwner's Name _. ..: <br /> �. 6 " --- <br /> Address0�1 ..1�. 'L.. •---•....City ............ V........ --; <br /> Contractor's Nome g ...F : A G- '�-�----...License - � �r --- Phone <br /> Installation will serve: _ ° ' Residence Apartment House Commercial OTrailer Courts 0 <br /> �. _. . # .. . Motel ]Otfief .------------------------------------------ <br /> Number of livin units:_ ; ..plumber of_bedrooms : ..:Garbage Grinder ... ....... Lot Size` ` .....__h . <br /> Water Supply- Public System:and name --- _ . -i=- .... ............�......._... ..... ........Private <br /> Character of soil to a dept.. of 3.--feet Sand 0 t Silt[3 .clay,Q R Peat I] -Sandy-barn i� Clay Loam-0 • _ i <br /> Hari pain[]i Adobe fl Fill Materldl . ... ..If yes,type...... .....:.�' a <br /> (Plot plan, showing size of lot, location of system .in'rela an-towells, buildings, etc, must be placed'on reverse slde.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 fast,) <br /> PACKAGE TREATMENT SEPTIC TANK ~ _.._. •-. .......•--•••---- <br /> 1' I< ] l __ , . o Saxe Liquid Depth i <br /> i - r Material <br /> Capacity. pe.-- t <br /> rtments <br /> = c r t undation Prop- Line ....................... <br /> -- o �,Compartments <br /> Distance.to nedrest: Well ---- .... ......... Foundation <br /> �_ <br /> LEACH.INGLINE [ j I No. of Lines ...... „§------: Long&of each line...........:......:--------- Total? Length• ., ................ <br /> filter-Materldl Depth .Filter Material <br /> D'.Bax -._. , Type..Pict ...., ---•• .......................................... <br /> � <br /> r ; Distance to nearest..Well!-........ -. Foundation Property Line ' •• . <br /> Si:EPAGE AT: ('( Deptfi '.-•-.'---._.a_-- Qiarneter .. N�imber' -_ ' _.. .--..__.. Rock Filled Yes o <br /> } ❑ N �] f <br /> Water-table Depth • ............... '_, <br /> ..........Rock Size .. .......................... i 5 . <br /> 4 = .. ..foundation Pr <br /> op. Ltne ............ ...WellDistance to nearest: <br /> C REPAIR/ADDITION(Prev, Sanitation Permit# ...... :..... <br /> i Date ................ ) v� <br /> .Septic Tank (Speclfy.Requirements) --•-•.... .. ..------.............. <br /> ff �� - <br /> Disposal Field (Specify Requirements) .._ .-•_,.... <br /> .,. _ . ------..... -.... --------------- <br /> ------------------ <br /> 9 .. .._..... <br /> ►_`(Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared.this,application,.and.that the:work will.be dans'in auordance with San Joaquin <br />+ County Ordinances; State Laws, and Rules and Regulatlons of the San .Ioociuln Local Health:District. Home owner or licen- <br /> sed agents signature certifies the following: I `w € <br /> " certify that in the performance of the work.for which this permit.ls Issued,1I shall n'ot,employ-any person its such mrtnner <br /> !' <br /> ast to become svb)ed ta'Workman's Compensation laws of California." <br /> Signed --- - - ° x` > '. <br /> R <br /> I <br /> B � 1 . <br /> other than owner) <br /> i FOR DEPARTMENT. USE .ONLY I <br /> APPLICATION ACCs PTSD 8Y _ •'f ' T_ .................. -----------------:-----P-----------------DATE 3.-:... . <br /> BUILDING PERMIT ISSUED.��:.-...............• •----•--•-------------...-.:...=----•----------...---------------- •----- DATE ... <br /> ADDITIONALCOMMENTS .............................. ----------------------------------------- ----------------------------------------------- .................................... <br /> ' <br /> ----------•-------------•- <br /> -.................... <br /> ..---.-.-.---- <br /> --•-- ---------------- <br /> ... <br /> ............ ........ <br /> ------------ - ---------------------------------------------------- ---------­---­------- <br /> ------------- <br /> -------- --- ------ <br /> ---------------------:--•-- ,•...••---- --- ----Date Inspection b -- ••-••-•------------------------•-----.. ....---•-----. ....-------'------- ...........--•-"- -- <br /> .. <br /> El13 24 1-69 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7a 3M <br />