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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> --- --------------------;----------------------- <br /> - � (Complete in Triplicate) <br /> Date issued <br />----------I-------------------------------¢------------ i <br /> ----- <br /> __ -- This Permit Expires i Year From Date Issued <br />-- ----------------- ------------------------ _ <br /> for a <br /> Application is hereby made to the San Joaquin Local Healtth,District nonce permit <br /> t and existing RulesandhRegulat tions.described. This application is made in compliance with County Na— <br /> f ►*�' -de_--fVn t 1 <br /> .3 A -CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATI N jS� U -J), <br /> O _lt /LfL <br /> Phone <br /> Owner's Name ,� <br /> �Address --- city <br /> 7 ------ <br /> Contractor's Name -"-��-"�----- -- <br /> b-A�.......... <br /> .._.License #I .-< ` Phone. <br /> Residence partment House,❑ Commercial ❑Traiter Court 0 <br /> Installation will serve: <br /> Motel ❑Other --------------------------------------- <br /> Number of living units:._--.___ _ Number of bedrooms �-----Garbage Grinder = � Lot Size <br /> -----------------•----- <br /> ' Private;�� <br /> I ❑ y <br /> - - ------------ <br /> _ <br /> Water Supply: Public System an name ---------------------------------------- - ,, <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cla211j;Qteria <br /> Peat Sand Loam ❑ Clay Loam:❑ - <br /> y e ---------------------------- <br /> Hardpan ❑ Adobe' l _ -- If es, type <br /> ti <br /> (plotbuildings, .etc. must be placed on reverse side.) <br /> ' plan, showing size of lot, location of system in relation to wells, ` f� <br /> NEW INSTALLATION:—(No'septic"tank or`seepage pit-permittedl•if public sew e i available within 200 feet) <br /> +� Liquid Depth - -- vv <br /> PACKAGE TREATMENT [ SEPTIC T; NK e T <br /> T e _- _ Material a" ' tea- Compartments - --=-----= - <br /> 0� 1 r?- ; <br /> Capacity ._�--v�-- Yp ��--^^- <br /> -01 1 d -__ Pro Line Z____,./-------- <br /> ____ Foundation --- -------- ----- p <br /> Distance to Weare)) Length of e <br /> k t I <br /> LEACHING LINE � No. ofeLmes each line---/--- <br /> LEACHING <br /> ��d Total Length --���•---------•-- <br /> f <br /> i <br /> k.De th Filter Material ___ _ _ <br /> 1 'D' Box ��--- Type Filter Material/ <br /> /,l -- ----�--- <br /> p <br /> I Foundation <br /> . -_ ___--._---_ Property Line - <br /> Distance to n�rest: Well " <br /> 3 ,� -__ Rock Filled Yes I`10 .0 <br /> Diameter -�-___-- - Number -_ -- --- ---�;- <br /> Si <br /> SEEPAGE PIT [ f Depth r�i -- -1°i`G,�l , /� " <br /> Depth <br /> Water Table Depth -- Rock Size <br /> 3 / A i <br /> � Distance to �earest: Well -___(--Q--�--- --•------- <br /> Foundation <br /> =-------- Prop. Line <br /> IDate ---------------------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------' <br /> f Septic Tank {Specify Requirements ' --------------------------------- '-------------------------------------- -------------------------------------------------------- <br /> -------------------------- -----•--------------- <br /> k Disposal Field (Specify.Requirements) ----------------------------------------------------- <br /> .1, tis t' , V ! ---------------------------- - -------------- - <br /> _ ---- <br /> -------------- <br /> { <br /> - -------------------------- <br /> ------------------------- <br /> ------------------- <br /> ----------------------------------- ---� +'__Y-'___--___---__---__-___--___--__--_______--___-1__ _-=____________ _ <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 done in accordance witfi San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations o�frthe San Joaquin Local Health District. Home owner or liven- <br /> " sed,agents signature certifies the following: p p ersan in such manner <br /> "I certify that in. a Performa ce of the work for which this permit is issued, i shall not em loy any p <br /> as to become a to Wok n's ompensation laws of California." <br /> Signed <br /> Owner <br /> q <br /> — <br /> Title _ <br /> .(If other than ner) ) <br /> FOR .DEP RTMENT USE ONLY nn <br /> APPLICATION ACCEPTED BY -- ----- - -- - - - ----- - <br /> DATE ---cam- ---I- -- <br /> BUILDING PERMIT ISSUED ---------- DATE _. <br /> ` ADDITIONAL.COMMENTS -- ------- -------------------- ------------------------ ----- --------------------------------------------------------------------------- <br /> ------------------------------------------=-- -- <br /> - -------------------- ------- I--------------------- ------------------- - ---------------------------------- ---------------------------------- ---- <br /> ---------- <br /> -------- Date <br /> _ ---------------------------- <br /> ,7 ifJ��is . <br /> �-, <br /> Final Inspection by:i_------------ <br /> _ �_- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c u 0 1-'68 Rev. 5M <br />