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FOR OFFICE USE: APPLICATION FOR SANITATION PERhPifT <br /> ..... ........................................... Permit No. .7T.:, t3 <br />.............-----y=.--... .... (Complete in Triplicate) (, 7� <br /> ...................I.-. -. <br /> ... , .-.-- This Permit Expires 1 Year From Date Issued Date Issued .................... <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. 54 and existing Rules and Regulations: I <br /> JOB ADDRESS/LOCATI N .. CENSUS TRACE <br /> Owner's Name ....... . ..-�.. ::........ � .__••_.........- <br /> ..Phone <br /> Address .............. <br /> � I <br /> Contractor's Name .. .... . <br /> 4.....� License #o2;Ce1*1_ .447P _ Phone . :. 0.. <br /> Installation will serve: Residence AApartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other -..........................--•-••-•-.:__-.-- <br /> Number of living units:.--- --- Number of bedrooms _t7..... g �- -e'C " ' ' <br /> .. ....Garbo a Gri®nd�er '.. .. -..- Lot Size .-.,����=--�..�.�.—�_._. <br /> Water Supply:,Public System and name .-. ........ .----�� ••..................................................Private ' <br /> Character of soil to a depth of 3 feet: Sand 0 Vt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam <br /> - Hardpan ❑ Adobe ' Fill Material ........ ... If yes,type ......-__---------------- <br /> -- <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 [ � SEPTIC TANK ' Size_ rx -- 1_ ..� .--• --- Liquid Depth .... -P___._...._.. <br /> Capacity/,0.&_d_�� Type Material.-1fif'.. _ _---. a. Comportments .. ..............� <br /> - _Distbnce. to °nearest: -Welit- _-_--_--....••-•-----•-•Foundation .-:-/,4r._-......._ Prop. Line ......�..._-.....�i <br /> LEACHING ZINE Na, of linesLength`of each line'" .___ '':___{ Total length <br /> } •D'-Box .-/----. Type Filter Material ."_.Depth Filter Material. /107.1 .......--..••..•.........--•- <br /> `, r <br /> Distance to',nearesti,Wel I -- ____..=.._ Foundation -Z.P_ Property Line ....r.............. <br /> SEEPAGE PIT Depth .a2.47'_.-._-. Diameter ��__._____ Number ...- ... ._ .,.-_.�... Rock Filled Yes j�' No <br /> .._._._..--Rock Size ....................... <br /> Water Table Depth -----�-�...� �€ _ -••t� �f � � <br /> Distance to nearest: Well AQ.e.oy.......... ............ Foundation '...._.:..-. Prop. Line ..' ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..............„......A.............. Date _.^".._':'"........ ............. <br /> Septic Tank {Specify Requirements) "i ... <br /> ............................... ........... ..•--•-••-••••---•••-........_..------•. ... ........---- _ <br /> Disposal Field (Specify Requirements) ,ems` ............... } <br /> .----.--•---......--•-•-••-•-•... ......... --A ---- ............... <br /> --........... ------------------------------------------------ <br /> - ...............04do.a .4 ? '.... <br /> ,, (Draw existing and required addition on reverse side) ? ' <br /> I;Wereby 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 Local Health District. Home-owner or [icon <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 in such manner. <br /> a's to become subject to Workman's Compensation laws of California." <br /> Signed ....... ............ Owner ' <br /> ......-•••- <br /> By .._..,.... � - -••••-••----•---•••--_.. Title ....-- . .......... . <br /> (lf otherthan owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED --- ---£--=--------------------•-•-----. DATE ....9- -.61---- -T_--------- - <br /> fBUILDING PERMIT ISSUED ...................••••--.............................-•--••-•---•....__....... _DATE <br /> ADDITIONAL COMMENTS <br /> ........................................-_....-------•....-------•---------------------------------._................--•--------------....._........................_•-••• ----•• ----.......... ......•. <br /> = -------------•--.....••--........------------•-----......................_... Z_...__. <br /> Final inspection by Date .. R <br /> -••---•..-•--•••••••-- ,. <br /> i - - • <br /> SAN -JOAQUIN -LOCAL HEALTH DISTRICT <br /> 7/77 1 M <br />