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FOR OFFICE USF: <br /> 4d APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- -- I Permit No: - - <br /> (Complete in Triplicate) <br /> .__..___ _ <br /> ..____-_ ______________________________________ t This Permit Expires 1 Year From Date issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ord' .once No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---- �1. / - <br /> -----------------------------------------CENSUS TRACT -------------------------- <br /> rl <br /> Owher's-*Name O . w... <br /> I '- -- <br /> Address --------------- �.,_�------_--------------- ---- ----------- -------..__. C1 ��f----------------------------------- .---•--. <br /> i q <br /> Contr_actor's Name - ._ f_/�_a �- c .��--.-.License #��4 /r __,Phone___________________.:.!_..____. } <br /> ��1.� � � � � - - . � # <br /> InstJotion will serve Res idence \�Aparttme:nt House°❑ Commerciai ❑Trailer�Court ❑ <br /> !Motel ❑ Others----- <br /> i Number of living uni -"°_ Number of bedrooms -------Garbage Grinder __--_; Lot Size <br /> Water 5u I Public_S stem and name _______________ _______ ___ - .--r ___Private <br /> pP Y.- y. ---------- = = _ <br /> Character of-soil to a depfh of 3 feet. Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> r t Hardpan ❑ Adobe'IZ Fill Material ------------ If yes, type ---------- _______________ <br /> i {Plot plan, showing size of loft, location of system in relation to wells, buildings, etc. must be placed on reverse sidej'j <br /> t NEW INSTALLATION: (No septic <br /> tankxor..seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT-j SEPTIC TANK.( ] Size---- -------------------------------- --------- Liquid Depth ------------:-------_.--_' \ <br /> 4 ' Ca tacit - - -------_" T ; -------------------- Material-------------------- - No. Compartments -------- ............. t�' <br /> Distance to nearest. Wel'' ------------------------------------Foundation -1 ---.---- ----� Prop, Line ---------------------- <br /> ,,__,,, <br /> LEACHING LINE% [ ] No, of Lines ------------------------ Length of each line--------------------�.__ -- Total Length ----------------------------- <br /> 'D' <br /> -------------------------- <br /> t 'D.' Box __1:`___.___ Type Filter Material ____________________Depth Filter Material __________ <br /> Ae <br /> Distance to nearest: Wel! _______________ ________ Foundation _--- <br /> __.______________.__ Property Line ------------ ....... <br /> SEEPAGE PIT De th�:_1 --------------_.Diameter_ ______________ Number _ Rock Filled Yes No <br /> © C] <br />{ WaterjTable Depth ------------------------------------------------Rock Size -------------------------------- P <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ---------.------------ <br /> REPAIR/ADDITION(Prev. <br /> -_---- - - <br /> REPAIR/ADDITION(Prev. Sanitation.Permit#-.==w-=------------------------------- ------Date -----------------------------_-__-} <br /> Septic Tank (Specify Requirements) ,t f�- -- ------------- <br /> -- <br /> Dis osal Field {Specify Requi ements} ------- <br /> _ -----,--- _ -�� � 4 ---------------- _- _--- - - -_-------- <br />! 1t <br /> 2e, <br /> t ------------------------------- <br /> {Difaw 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 •n the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be bject t orkgpgn a Compensation laws of Califorria." <br /> Signe -- -'-- ----- - / -- ----' -i- x -t----- 0'-- ----------------- <br /> BY ------ ---- ----- ---------------------- --------------- :------- -Title ------------------------------------ --- -- - - <br /> (If other than owner): <br /> --FO EPAVMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------I- -- - r ----- --------------------' DATE I Q <br /> BUILDING PERMIT ISSUED ---------------- ---------------- DATE ---- L <br /> qrD iTfON L COMMENTS -- - - - �.: � : �,---- eE • <br /> b 46t- ------... ,r � ��'~- `� tori <br /> -------------------------------------------------- - ---------------------------------------- - ---------------------------- - r <br /> ----------------- --------------- <br /> ---/- ------------------------- <br /> Final Inspection b tl -- <br /> p Y- ----- .__ -. �--- - - - - --- --�---------------- -- ----------------------- -Date ---'�� -'"- J <br /> N QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M• <br />