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FQF,.OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No. <br /> - (Complete in Triplicate) <br /> Date issued ---- <br /> ------------------------------------------- <br /> --- -----• - <br /> - ----------------------------- <br /> ---------=------ -- This Permit Expires 1 Year From Date issued <br /> , <br /> - <br /> ---------------------- --- --- : �. <br /> alth <br /> rict for a <br /> rmit to construct <br /> A plication is hereby made.to the San JoaGdance with CouDytOrdnan a No. 549 and existing RulestalndhRegulations: ` <br /> p application is made in comp <br /> described. This app CENSUS TRACT <br /> JOB ADDRESS/LOCATION ----------- 11 -------------------Phone ____ <br /> Owner's Name ----------•,�-- I <br /> _ --- CitY -- <br /> --- _ --------- ` <br /> Address -------- -- -------- - -- ------ ``� �� _ _ Phone <br /> Contractor's Name ------ <br /> installation will serve: ��, <br /> esidence partment House Commercial -❑Trailer Court ,❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:____----- Number of bedrooms -�-----Garbage Grinder Lot Size --------- <br /> ------------------------Private <br /> Water Supply: Public System and name ---------------------- Sandy Loam Clay Loam 0 <br /> Sift Clay .❑ Peat❑ <br /> Character of soil to a depth of 3 feet: Sand❑ ❑ e - <br /> Hardpan ❑ Adobe ❑ Fill Material -____--____ If yes,type <br /> of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> (Plot plan, showing size of lot, locationY <br /> it permitted if publ'c sewer i available within 200 feet,) <br /> NEW INSTALLATION: (No septic tank or seep <br /> ge p p . <br /> Si C,� -- ---------------- Liquid Depth ..---.-- -----. <br /> PACKAGE TREATMENT j ] SEPTIC TANK �. , ._- <br /> . ^ ----,.^�� No. Compartments ._:: .: <br /> Ma#er1Ql-- j-- <br /> Capacity -I �r'" Type r I <br /> i ---=Foundation _1- -�" ------- prop. Line __ --- <br /> Distance to nearest: Well _--_---- ---- -- Tota! Length <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line____---------------- <br /> 1 T e Filter Material -------------------:Depth Filter Material -------------•------------------------------ <br /> D' Box -_____- __-- Type k Property Line <br /> __ Foundation ----- ----------------------------- <br /> ,Di.stance to nearest: Well ---------------- <br /> ------ <br /> _:------------ No I❑ <br /> h- -.mss, ..°k Number Rock Filled Yes ❑ <br /> .7 tki Diameter _ ~-- -------- <br /> ---------------------------- <br /> R SEEPA PIT [ } " � <br /> '_Rock Size <br /> Water Table Depth ------------ ----------- - <br /> -------------- <br /> ,..-... - ---- _. , Pro Line --__------•-----•----- <br /> ----- Founda#ion -------------------- p. <br /> Distance to nearest: Well --------------------------------- . <br /> ---------- ------------------------- <br /> -------) <br /> 17 <br /> REPAIR/ADDITION(Prev. Sanitation Permit#'_- <br /> ------------- <br /> .. <br /> Sepfiic Tank (Specify Requirements --------- -4 <br /> a R .. -- <br /> .Disposal Field (Specify Re uiremen#s) ---- — -�—— ' ----:: <br /> ' ----------- --------------------- ------------ <br /> --------------------------------------- <br /> = ---------------------------- ---------- <br /> -------------------------- -- ----------------------------------------------- <br /> - <br /> ----- - {Draw existing and required addition on reverse si,e) <br /> 1ne in <br /> I hereby certify that 1 have prepared this,iapplicati pd that <br /> the San Joaquin will be <br /> doHal, ealth DistSO" Joaquin <br /> rc t nce Homewo <br /> towner or licen- <br /> County Ordinances, State Laws, and Rules and Regulations <br /> sed agents signature certifies the following: �-4 <br /> "I certify that in the performance of the v °rk Non claws of California." <br /> is issued, I shall riot employ any person in such manner <br /> as to become subject to Workman's Compensation t <br /> Owner <br /> Signed -----A.ff, - -- --------- - - -- ---- -- -------------------- <br /> --- <br /> ----------- - Tit e - <br /> (if of than o r `' ' ' <br /> r ++FOR-DEPARTMENT`USE ONLY <br /> DATE �� �� ------------------- <br /> --------------------------------------------------- DATE -- --------------------------------- <br /> APPLICATION ACCEPTED l3Y _---------- --=-- --------�- ------- - ------__-_ <br /> ------- <br /> -------------------------------------------------------------------- ------------------- <br /> BUILDING PERMIT ISSUED rt _ <br /> COMMENTS -------------------------- 'ri.j .� : ------------------ <br /> ADDITIONAL <br /> ----------------------------------------- ----- ----- <br /> - , _ _ ----- t� r f <br /> ' __ _ ----------------------- _ __ - ------ ^_Date _. <br /> Final,lns ection b - <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ <br /> E. H. 9 1-'68 Rev. 5M <br />