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FOR OFFICE USE: � - <br /> a � ,_ _ - AP LICATION FOR SANITATION PERMIT <br /> ......................�_........::................._.. "Permit No. .................. <br /> Moon; In TriplicatO <br /> ::..::.::..:...... " ... - Dal!Issued <br /> Date Issued ..6.. 77 <br /> ............ .......... . .. .... This Permit Expires 1 Year from _ <br /> Application is hereby made to the Son Joaquin:local Health District for a permit to constrtict and install the work herein <br /> described. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ­_ <br /> G...... CEN$US TRAGI _ <br /> JOB ADDRESS/LOCAT ---. i - = .......................... <br /> Owner's Name '/ _ � � .......... ............Phone . .� .. <br /> Address . , ,+ , ..:City G ...................• ... ....... <br /> ' <br /> i -- <br /> .... / <br /> Contractor's Name _ --------------•--•----- <br /> _License # ................... Phone <br /> Installation will serve: Residence j0 Apartment House Commercial❑Tralier Court ❑ <br /> Motel ❑Other-------........................-......... <br /> :.. f <br /> Number of living unit!.-.../ Number-o# bedrooms _.._Garbage Grinder ....---:.... Lot Size ...__. ....2� .. . .. .............. <br /> g <br /> fWater Supply: Public System and name ......................................................_.__ ..-_:_.... ..........................................Private- <br /> Character of soil to a depth of 3 feet: Sand W Silt 0 Clay p Peat.Q Sandy Loom{> Clay Loath❑ <br /> Hardpan❑ Adobe o '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) ` y <br /> PACKAGE TREATMENT .[ ] SEPTIC TANK{ ] -:-- Liquid Depth .............:............oo <br /> Size---•. ...............:..........•-_:-__. . <br /> Capacity.................- Type .............. Material..................... No. Compartments ...................... <br /> Distance;to. nearest:-Well ............. .-- - <br /> ..:......foundation _. ---Prop. line ........._,,.:.. - S <br /> LEACHING LINE [ No. of Lines --. Length of each line..._...:............ Total Length � <br /> :'D' ®ox Type Filter Material Depth .Filter Material ..... ........ <br /> Yp ................... <br /> Distance to nearest: Well ......___......._....... Foundation ......................... Property Line ........................ - <br /> SEEPAGE PAPIT [ I Depth <br /> ..,.--•------------• Diameter ----•_----:....: Number ............................ Rock Filled -Yes ❑ No <br /> Q <br /> Water Table Depth ....Rack Size ._..:.................... <br /> Distance i <br /> to nearest: Well ---._..----•............................Foundation ...........:........ Prop. Line <br /> ....:.........---•--•- <br /> REPAIR/ADDITION IPrev. S"dQr itation:Permit ------------• •--• =---- to --• .......:•.............} <br /> i <br /> Septic Tank (Specify Requirements). x- •- ...02 .....................,........_.-•-•---.......... <br /> Disposal Field (Specify.,Requirementsi ----------•----------•------------r--------------•------ ...:.. ---- -------- --•,•----•- ;,.. ...................... 1 <br /> ..........................................=....... -----------_-__............-....... --.....-- ..... <br /> ................................................ --------------------------------- ..........-.............•...... .:.:.:---.....--- _......... ......... --•--- <br /> 1 {Draw existing and required addition on reverse side) <br /> I hereby certify that,I have prepared this application and that the work W"'.r be done in accordance with San Joaquin <br /> County Ordinance _ a aws,•and Rules and Regulations`of.the San 'Joaquin Local Health.Disirfct. Home owner or !icon- <br /> sed agents si turecertif' a the olldwing: 3 <br /> ".I certify t tin th r n f the wok o which this permit is issued, I shall not employ any person in such manner <br /> as to a ie W n' C ws of California." <br /> ' Signe .... ....... . . ----------- Owner f <br /> BY ------------------------ ------------------------------- ... . .................................. J1 tle ----------•---- .................. ---------------- ......... ••--• <br /> (I# other than owner) <br /> r FOR DEPARTMENT .USIM ONLY .•- <br /> ' .RATE_..................... f... ----------- <br /> ....1��. = <br /> APPLICATION ACCEPTED- BY _r -- __-- --, - • --• --••-•---- ....................... <br /> BUILDING PERMIT ISSUED _--------=----- ._...DAT ---•....................................... <br /> ADDITIONALCOMMENTS ...................`...-.__..__..----...._...........-•------......__.._........_..._..----.:-_._.....-----•-•-•------------ •-•---•.....--:._......_._..__..-. <br /> ---------------- -----------------------.I..... -------•--•••----------------------- --------------------------------------------- <br /> --------- <br /> - <br /> ._...__... L Date ........Final Inspection b <br /> EH 13 24 1-63 1 v. SAN JOAQUiN LOCAL HEALTH DISTRICT 8/74 3M <br />