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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT Y <br /> -----.------- ------------------ Permit <br /> (Complete in Triplicate) <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issued . __:_- :_?L <br /> Application i he by m to the San Joaqu' focal Uealth District for a permit to construct and install the work herein <br /> descri c�T i pli i co i t County Ordinance No. 549 and existing Rules and Regulations: <br /> L� Gia !1� <br /> J08 Ab E /LO TION .- -- -f---------� '�'�---d-�----f�/'T�f�-_�_� — - - CENSUS TRACT -------------------------- <br /> Owner's Name SlgX4----4�,_4 ----------------------------- ------ <br /> Address ----------------------------- -----------CityQ _L1`7`"ash------------------------------. - ---._----- <br /> Contractor's Name ------O2 1­VV--C License # - Phone + <br /> Installation will serve: Residence (Apartment House❑ Commercial ❑Traller Court ',❑ <br /> Motel ❑ Other -------------------------------------------- <br /> r ti I <br /> Number of living units:---A-_____ Number of bedrooms ____f-----Garbage:.Grinder _ Vdf----- 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 /> � v <br /> Hardpan ❑ Adobe ❑ Fill Material ------ ----- If yes,type _-________________________ _ <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 /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ------------•------------- <br /> Capacity '--------------_ Type __________________ Material_� +Ft _ No. Compartments _ -__________._-:.... <br /> p Y - Yp -------------------- _ <br /> Distance to nearest: Well -------------------------- Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE 4)0-0 No, of Lines ____/------------------ Length of each line____-_ 5 ----- Total Length <br /> 'D' Box ____ _�_.____ Type Filter Materia! ____Depth Filter Material _A4 _______________________________ <br /> Distance to nearest: Well _14.517_______________ Foundation ____ --------- Property Line ------------.__.___-____ <br /> SEEPAGE PIT [ Depth la I ---------- Diameter Number ____ ______________ Rock .Filled Yes [�, No i❑ <br /> Water Table Depth Q-----------------------------=--------Rock Size - ------------------------- <br /> Distance <br /> ----------------_----Distance to nearest: Well G______________________________Foundation fz_________.____ Prop. Line <br /> -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date.-_-----------.-------------------_) <br /> Septic Tank (Specify Requirements} -------- -------------------------------------------------------------------------------------- f ------- ------ { <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- w <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 become subject to Workman' Compensation laws of California." <br /> Signed --------------------------------------------. Owner <br /> BY ----------------------------------------- - ---- ----------- Title ------------- --- <br /> (If other than owner) ' <br /> T USE ONLY <br /> APPLICATION ACCEPTED BY -------------- -- --------- ---- - ----- - DATE -----4 Q---7 ------------ --- <br /> BUILDING PERMIT ISSUED ------- ---/ - -------- ----- -- DATE --------------------- ------ <br /> 1AITI0jNA O �T5 _4 _- f cP `� ------- -- ----r----Final Instion by: -------------------------------------------------------------------- ------------------:----------------------- ` <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />