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FOR OFFICE USE: q 6 w t(11b2J (z i ( <br /> ----- ---------------------- <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ------ ------------- <br /> (Complete in Triplicate) <br /> /5, <br /> ______________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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. 549 and existing Ru es and Regulations: <br /> � p� <br /> / c -� ��_. NSUS TRACT <br /> JOB ADDRESS/LOCATION . •Szt'1 O _/e� __ -__ . <br /> Owner's Namec=P% - ----------------------------------------- //// Phoned' .------------------------ <br /> Address <br /> - r--- <br /> -- �*l wvcr le 1------ <br /> Address ----------vI�SBQ _71t----- -- ---------- City fle& flASV_ _t9----------------- <br /> Contractor's Nam -------- ` . -- - --- -_C _ -1----------- # ___- Phone <br /> Installation will serve: ResidenceXApartment House❑ Commercial [-]Trailer Court ❑ <br /> j Motel ❑Other ------------------------------------------ ( / <br /> Number of living units:------- Number of bedrooms . --- Garbage Grinder _______-___ Lot Size _. __� _�±---` ...... <br /> Water Supply: Public System and name -._____________________ _ ---.._-_________.__________....______Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay '❑ Peat❑ Sandy Loam ❑ Clay Loam❑ <br /> Hardpan ❑ Adobe 5_4 FiN Material ------------ If yes,type .---___-_-________--__.-_- <br /> (Plot plan, showing size of lot, location of system in relation t >,wells, buildings, etc. must be placed on reverse side] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pub is sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ize _�_ ._ .Q�� __ 'u _______ Liquid Depth __640 ��.___._..,, <br /> w <br /> Capacity 11-Z-0-A0----- Type Material- No. Compartments _2.......... <br /> Distance to nearest: Well l 001------- <br /> - '_____________Foundation ____L_0-'t-------prop. Line -__-_�. <br /> LEACHING LINE No. of Lines _____ _________________ <br /> Length of each line.-__��_�_____-______ Total Length _Q. ............ <br /> 'D' Box ------------ Type Filter Material . __.r ___Depth Filter Material ___ _ _------. ........................ <br /> Distance to nearest: Well __ _o-0)-___-____ Fou ation ___1A- Property Line --------- -. ---------- <br /> SEEPAGE <br /> -----_SEEPAGE PIT Depth _______________ ___ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------•------------' Q <br /> Distance to nearest: Well ----------------------------------------Foundation _________._-_.-. --- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---___-__-___-______--____-__-____) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------•--------_---------------__------ <br /> DisposalField (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------. <br /> ---------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------=-------------- ------ <br /> ----------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------- - <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 with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. 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 in such manner <br /> as to b PALI Uec RLdimW6C'wvm on laws of California." <br /> Signed ---------.-t$ou-tEA& --- RANTLINt*__ROAD---------- - --- --- -------- <br /> By <br /> - 9w�er� <br /> P, O. BOX 254 <br /> r Title <br /> (If other than owner) <br /> R DEPARTMsE�NT SE-. ) LY <br /> APPLICATION ACCEPTED BY -------------------------------------------- :_. DATE ---- �� �' •------- ----------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------ ------ ---='--------- -..r' ---DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -----------------------------------------------(---; '--- •-----E/ - -------------------------------------- --------- <br /> --------------------- ------------------------ ---------------------------------------------------------------------------------------------------------------- ------------------------------------ <br /> -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- <br /> --------------- <br /> - ------ ---- - - - -- - - - -------- - -- <br /> r _ - � --- ----- <br /> 7 ._. __-___Final Inspection by: ------------------------ - -- --- -----------7 ___________Date <br /> SAN JOAQUI�r <br /> _ LO>LAL HEfH STRICT <br /> E. H. 9 1-'68 Rev. 5M � _ a F,f <br />