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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT w 71 33) <br /> <. Permit No- --------------------- <br /> (Complete in triplicate) <br /> �---- <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,Coufity-Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA710N __/-h// /-(�-3-�----�-----�-�W�_�N-C�-------------------CENSUS TRACT ___J_ _-�-�-C�--------- <br /> Owner's Name -- ` ---- FI a- - Ph on --------------------------- ------ <br /> �- b <br /> ` -1 -------6- <br /> Address -----� -� , -----------���_���C�-----------•--� City ------------------------------------------------------------- ------ <br /> Contractor's <br /> --------------- ------------- --------------•--- ------ <br /> Contractor's Name -------------- ------License # ---------.--------------- Phone ------------------------ =--- <br /> ---- - ------------ <br /> Installation will'serve: Residence Apartment House 0 Commercial:❑Trailer Court ❑ <br /> Motel ❑Other-- <br /> -------------------- <br /> of living units:-_�_�_'_-Number of bedrooms _______Garbage Grinder��.S- Lot Size-_/k, ---------- <br /> ----•- ------------------------------------------ --_-P vate <br /> Watef Supply: Public System and name __ ________ -� �_- i ri <br /> Character of soil to a depth of 3 feet: Sand ❑ Si ❑ Clay ❑ Peat❑ Sandy Loam •❑ 'Clay Loam <br /> -- Hardpan Adobe ❑ Fill Material --FtF(9___ If yes,type-_______._L-�`---------- <br /> a. - <br /> .yam � .� \� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be pl'aMced on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seeps it permitted if ublic-rsewer is availablywithin 20D feet,) fr <br /> PACKAGE TREATMENT { ] <br /> SEPTIC TANK Size:=`�__----/a x_-_�_�-------- Li id Depth ---- a--. -----.----- t,1 <br /> Cap city _� TypeP E�3- Material C 3AB �No. Compartments z------ <br /> f Q_ _ Pr6 Line <br /> istonce to nearest: Well _-------- --------------Foundation ___ __ __-_---- k P• -I,�-t <br /> - _ Total Len`th ------1: --..-. <br /> LEACHING LINE [ No. of Lines`_-� ________._ Lepgth of each line_____ • ^-----:----- - 9 <br /> 'D' Boxy Type Filter Material _(")�_C�.Depth filter Material -------!_ ---------- ----,_____-- Lt <br /> -�- ° f - ______ Property Line +` �j <br /> Distance to nearest: Well _-_ ___- Foundation __ __- <br /> _ Number ______l- Rock Filled Yes No i❑ <br /> SEEPAGE PIT { p Diameter ___ ,. i <br /> Depth / ----- -- f <br /> Water Table Depth ----- _ Rock Size/ -y_____f/!;7- f <br /> / I <br /> �11 ._Foundation l Line :� --------------- <br /> Distancer� <br /> to nearest: Well Jea _ j� Prop. <br /> REPAIR/ADDITION(Prev. Sanitation Permit#;---------------------------------------- Date ---------.----------------•-------) <br /> Septic Tank (Specify Requirements) -------------------- ------------------- -- = <br /> --------------------------------------------------------------- <br /> -------- <br /> Disposal Field (Specify Requirements) ------------- --- ------------ ---------------I—'----------- <br /> ------------ <br /> ----------------- ------------------------------------------------------ ------'[-:::: <br /> ----------------------- --------------------------------------------------------------------- <br /> --- --- - , <br /> (Draw existing and required addition gn reverse side) r <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:ttome owner or licen- <br /> sed agents s' nature certifies the following: " �, <br /> 'I certify th a orma of the work for which this permit is issued, I shall not employ arson in such manner <br /> any p <br /> as to bec subje Wo n's Compensation laws of California." ! <br /> f <br /> Signed --- - -- ----------------------- --------- Owner <br /> By --------------------- --- ----------------------- Title ----------------------- ------- ---------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT, USE.ONLY <br /> ' APPLICATION ACCEPTED BY ---------- -------------"-----------;------------------------------------- DATE ------ '"7--- <br /> BUILDING'PERMIT-_ISSUED --------- _ ------DATE ---_------•---------+---------- --------- <br /> ADDITIONAL COMMENTS --- ------• -----------------.:-•----- �-- ---- ---------- ---- ---------------------------------------- <br /> _ - -= --------- ---------------- <br /> ---------------- <br /> -------------------- ---- ----- ----- - - ----- <br /> -- A- ---- ---­ ___ __ _ .. <br /> v <br /> - - _ - . _ <br /> ---- <br /> Final Inspectio = 2------------------------------------- Date ----- - -- - <br /> ,` j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />