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^ 012 OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------- --- ------------------------------ - <br /> 7 <br /> '�. <br /> (Complete in Triplicate? Permit No. <br /> _ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is:hereby made to the an oaquin Local Health Districtf4or% a permit-to construct and install the work herein <br /> vt ,-0 <br /> described. This application' is math �ciianc=- r <br /> `� to Nod5.4�,.and lexistinga,kules'iand Regulations:J[1 JOB ADDRESS/LOCATION ---- ----------------- --- 1�/Vl --CENSUS TRACT <br /> Owner's Name -I- --`----- � --t------ i _P_ n- TIES{. ---------------Phone 1rl�Z6_&_3-Q------- <br /> Address f' '. � /-y J---1Ti jP194 l City %_.-'f7----- ------------------------------------------------------------ <br /> --------------------------------------"-- <br /> ` <br /> Contractor's Name ________ <br /> . 1� ---------.License # D-�f--- Phone41IJ4LL_%1" 70-7---- <br /> Y <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------- <br /> Number of living units:)r�-- _ Number of bedrooms ,3-----_-.Garbage Grinder _NA. - Lot Size - ck_-7�- ------------- <br /> Water Supply: Public System.and name ------------------------------------------------------- --------------------------------------------- -------Private <br /> Character of soil to a depth of 3 feet Sana ..Silt0 + Clay .❑ Peat E] Sand Loam ❑ Cl Loam E] s <br /> =Hardpan ❑ Adobe'Q Filf 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,) C <br /> PACKAGE TREATMENT [ ] SEPTIC TANW Size4X______ __ ____ �t ~`"� <br /> _ ` / Z ,X-�'-----"--��- liquid Depth _��__�_�-�___.----•---••_-- ' <br /> Capacitya410_ ._______ Type IFROW17Material__ _ --___ _ No. Compartments .. 1 <br /> ��-- Foundation 3�O <br /> Distance to nearest: Well __�%------- _---"___-.- ____ _ Prop. line ______________________ <br /> LEACHING LINE No.`of Lines ____ _______________ Length of each line__._��--.------ --- -- Total Length _-_______-_-__ <br /> 'D' Box 0)--- Type Filter Material __z_ __KX__Depth Filter <br /> ilIter Material _`__.�/_'___ _____________________---.__--._ <br /> Distance to nearest: Well &0-------------- Foundation �_1p______________ Property Line--70t ---__-------- C <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number .__-.__--_ ----------------- Rock Filled Yes ❑ No iQ <br /> Water Table Depth -----------------------------------------r7koek Si e ----------------------- ------ <br /> Distance to nearest: Well ---------------------------------)----..Foundation -------------------- Prop. Line -------------- <br /> REPAIRJADDITION(Prev. Sanitation Permit#'�---.a''�:--''-'-_'""` '- --%j--- Date ____1---------------------------- <br /> Septic <br /> ___________________________Se tic Tank iSpecify Requirements, 0 1 k_ 11 <br /> Disposal Field (Specify Requirements)—'___°�-^•_-� •� )-_______ _______"_______________ <br /> ------------------------I----------------------------------------------------------------------------------------it------------------ <br /> -------------------------------------------=---------------------- <br /> ------------------------------------ ------------------ ---------------------------------------E----�--� 1 <br /> prepared(Draw expspting and.required�adclitFon on reverse e3� )e in accordance with San Joaquin---- <br /> County <br /> I herebycertifythat I have this application and that#tthe Work will b <br /> we_.,r d _—.-- <br /> County Ordinances, State Laws, and Rules and Regulation'the San ,foaqum'�Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that ' the performance of theworkfor.which this permit is issued, I shall not employ any person in such manner x <br /> as to beco su ject toy W ,kman's Compensation laws of California." <br /> Si ed d'--` ------ �--- Owner <br /> BY `'t[� Q---------- - _. _ Title <br /> oche than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYj " �. DATE �' is <br /> BUILDING PERMIT ISSUED ---..--- ---- • -------------------------------------.:_DATE - ''"'`'"` <br /> ADDITIONALCOMMENTS -------------- - - -- ------------- ------------------------------------------------------------=-------------------------- 1 <br /> � <br /> ______________________________________i_. __- -__k----------------------------------_____-__-_______ <br /> - - <br /> _________________________________________________ <br /> ---------------------------------- --- _ ---------------t # �. <br /> ____ _____________________________________________________________________________ ______._______.__-_______ <br /> ____ __ __ <br />< Final Inspection by: - ----------------------------}-----------.-T---- '_------------------------- .Date -. �J� -2.7------------------ j <br /> ftSA}N JOA. UIN LOCAL HEALTH DISTRICT <br /> H. 9 1-'68 Rev. 5M Ilk <br />