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FOR OFFICE USE: APPLICATION Fop. SANITATION PERMIT Permit No. - -------- ------ <br /> OR OFFICE USE. <br /> - ------------------------------------- (Complete in Triplicate) <br /> ----------------- <br /> Date issued <br /> ——-------------------------- <br /> This <br /> —_- J_ <br /> ---I------- --------------------------- This Permit Expires I Year From Dateusued <br /> ---------------I-------------------------:--------------- an Joaquin Local Health District fora permit to construct and install the work herein <br /> Application is hereby made to the S 0 549 and existing Rules and Regulations: <br /> n is made in compliance with d6unty Ordinance N <br /> described. This app • l---------- <br /> -----CENSUS TRACT -:7� <br /> Ph --------------- <br /> JOB ADDRESS/LOCATION ------- -- ----------I------ -------------- -------Ph --------- <br /> ------------------------- -------- - <br /> Name .... ------------------------------ <br /> city __40---------------r----- - <br /> Address --------------- ------ --------------- <br /> License <br /> Contractor's Name ---- -- <br /> Residence 0 Apartment House-171 Commercial []Trailer Court <br /> Installation will serve. Motel 0 other ---------- <br /> Number of living units J�_"'Nurnber of bedrooms /---------Garba-ge Grinder ------------ Lot Size --- <br /> -� <br /> Private <br /> --------------- <br /> Water Supply: Public System and name --- -.4--------------------- t F1 Sandy Loam Clay Loam IM <br /> If 4 <br /> Character of soil to a depih of.3 feet. Sand'[D.I.Silt 0 Clay D ' Peat <br /> type ---------------------------- <br /> Hardpan Ej -Adobe'D Fill Material ------------ if yes, <br /> i ti. I­_ ­�. 1� f- -- must be placed on reverse side.) <br /> in relation to wells, buildings, etc. <br /> (Plot plan, showing size of 1'61�,�focation'-of system available within 200 feet,) <br /> .N, -i 04e pit per: itted if public sewer is <br /> NEW INSTALLATION. (No septic tank or seel, 7 Size Depth ---------------- <br /> If ----------- Liquid <br /> ------------------------------------- <br /> PACKAGE TREATMENT SEPTIC TANK�4 <br /> .4 1�e Type --------------------- Material---------------------- <br /> No. Compartments ---------------I......... <br /> Capacity --------------------- Foundation ----------------------I Prop. Line ---------------7------ <br /> to nearest: Well ----------------------------- ------- <br /> Distance ------------ Length of each line-_------------------------- Total Length --- ---------------- <br /> LEACHING LINE I No. of Lines ------------- -------- <br /> ----------- Type.Filter-Material --------------------Depth Filter Material ----------------------- <br /> 'D' Box — . -. [ ---------- Property Line. --------------•--....--- <br /> i . <br /> .Well ------ --------------- Foundation ---------I----- No <br /> Distance to nearest: W <br /> Diameter ---------------- Number ---------------------------- Rock Filled Yes ICI <br /> SEEPAGE PIT Depth ------ Rock Size ------------------ ------------- <br /> k ............ <br /> Water Table Depth --- ------------------------ .-Foundation -------------------- Prop. Line ---------------------- <br /> Distance to nearest: Well -------------------------------=--------Foundation <br /> ---------:---- <br /> IDate ---------------------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ ----------­­----------------I------------ <br /> ) I ents) -------- ---------------------------- --------------------------------------------------- <br /> Septic Tank (Specify Requirern -- --------!- ------------------------- <br /> Disposal Field (Specify Rej�Ljirementsl <br /> ---- ------------------- --- <br /> ---&_q---------- ------------'le.1-�_ -------------------------------------------------------------------------------------------------------------- <br /> - i-,�k-- --------------------------------------------------------------------------------------- -I--------------------------------------------------------- <br /> ------------------------------------------- - <br /> (Draw existing and required addition on reverse sl el <br /> ne in accordance with Sun Joaquin <br /> application and that the work will be do <br /> I hereby certify that I havepr#pared this a, Health Distelct. Home owner or licen- <br /> County Ordinances, State Lowi, and Rules and Regulations Of the Son Joaquin Local manner <br /> secl_agents.signature,certifies-We following: loy any person in such <br /> "I certify that in the performance of the work for which this permit is issued, I shall not emp <br /> as becoT!, biect to Workman's compensation laws of California." <br /> 0 ""1" . owner <br /> to 'e <br /> ---- -- --- ---- -------------------------------------- <br /> ned --------- I---------a; ---------------------------- <br /> 21g T <br /> By ----------------- ---------------- - itle <br /> (1i other than owner) F DEPARTMENT USE ONLY <br /> -------------- <br /> DATE ----- ------------ <br /> APPLICATION ACCEPTED, BY ------ -------- ................... ------------------ ---- ------ --------------------------- <br /> BUILDINGPERMIT ISSUED ---- ---------------------- --------------------- -------------------- ----------------------------------DATE -------------- - -------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------ <br /> -------- ---------------------- ----------------- - - ----- <br /> -- ----------------------- ---------------------i---------------------------- ------- ----------------------------------------------- -------------------- ------------ <br /> --- - ------- ---- <br /> ------------------------------- ----------- ---------------- ------------- --------------------- ------- <br /> ------------ -------------------------3�---- <br /> Date - <br /> Final Inspection by- ------------- - <br /> SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />