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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ........................................••----- Permit No. ....... ...._�_... <br /> (Complete in Triplicate) <br />...................... .......................... <br /> • Date issued ...:5...-.~..... <br />...................................................,..... .. This Permit Expires i Year Front Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install 1he work herein <br /> described. This application is made in compliance ith County Ordi a No. 5491 and isting Rules and Regulations: <br /> � ,• s �t 11 <br /> JOB ADDRESS/LOCATION-�:.. t.:`. .t.C ._, . t.. _ 14 :..._.... !''.S,- 1..............C�NSUS TRACT ..--•-----..._.....,...... <br /> Owner's Name ...... ........_ •-•-•-.......... ..Phone ... ................................ <br /> Address ..... ..� (�. ..... Cit /)0Contractor's Name ...... F" -----....... ••.......::................License #�'�.�.1.� - ,CJ Phone .... = <br /> I/ a <br /> Installation will serve: Residence partment House[] Commercial []Trailer Court 0 <br /> Motel ❑Other ............................................ ; <br /> Number of living units:.-J..____ Number of bedrooms .......Garbage Grinder , _ Lot Size ..�./- •• /--1---- <br /> Water Supply: Public System and name ................................................... ....................................................... <br /> ....Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam .0 Clay Loam C] j <br /> Hardpan ❑ Adobe ill 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,) i <br /> PACKAGE TREATMENT [ j SEPTIC TANK .. <br /> ... -o .....1�................ Liquid Depth ...--. Z........... <br /> i, <br /> J <br />! Capacity --1.��p`�-. Type�� _Materia --- -- No. Compartments .."'L...1......... <br /> Distance to nearest: Welles p. <br /> ... Pro Line .. <br /> __ ........�. ---------Foundation . ..--�---- •-• •--•--•---• <br /> --LEACHING LINE No. of Lines ..Lp----.___.____--- length of 'arh line--- . Total Length' /.....0............. <br />{ D' Box Type Filter Material �'�f.....Depth <br /> /Filter Material .....1.. .�--.-: .................. <br /> Distance/to nearest: Well ..... .,.s..�., -� Foundation / l Property Line 4 ... <br /> SEEPAGE Psi' 0,1, Depth ...... Diam�etter t,�.J.-. Number ----.�._........._. Rock Filled Yes Ifo � <br /> Water Table Depth --------.,1�..-•..--.-••----... ........Rock Size _ ,lL.=. �......_._ . <br /> Distance to nearest: Weil -------- ------------J........--.--...Foundation ..Z............. Prop. Line, <br /> -.___..._..------ <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# .................I.......................... Date ..................................11 <br /> SepticTank (Specify Requirements) .......................................................................................---..........-•-•--........-----.................:_... <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------•--•-• ----•----- <br /> ------ <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's Compensation laws of California." <br /> i Signed ................... . ............••--..---_.. -_.. .................. Owner <br /> BY Title <br /> ------ ....... .... .. r ----_. <br /> (If of er t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> APPLICATION ACCEPTED BY -- •.............••-----............---------------------..._... DATE ...... _�?. 7.� ............ <br /> BUILDINGPERMIT ISSUED ... ....... ...................................-..........................................I..............DATE ...._ ..................... <br /> ADDITIONALCOMMENTS .............................................................................................................-..-.................I.----------•............... <br /> ..............••------••--•-•----•••-•--• . -_..... . --•=--•-•-••--------• --------------------.........-.----------------------............................... <br /> . .... -•------------ --- <br /> ......... <br /> i Final inspection by: 1- �. •..._.Da ..:�.�- ------------- --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Jyl , <br /> _ ,. to 9G. -- 71723M <br />