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FOR OFFICE USE: <br /> ------- ---------------------- - -- - -- <br /> - -- <br /> -------------- APPLICATION FOR SANITATION PERMIT <br /> ---------------- <br /> --------------------------------------------------------------------- (Complete in Triplicate) Permit No. <br /> --- <br /> -------- -- <br /> - -- Th- <br /> - <br /> - <br /> ---- s Permit Expires I Year From Date issued Date Issued , - <br /> -- i '/7 <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 Ordinance No <br /> 549 and existing Rules and Regulations: <br /> J013 ADDRESS/L6CATION .--/ <br /> Owner's Name ------ CENSUS TRACT <br /> -------------------------------- <br /> w Of r/w- ----------- ---------- ------- ............ <br /> Address ---------------- ------ -------------- --------- ----------- -------Phone - _ <br /> Contractor City AUO�T4ZC4 <br /> It-XA0yW ---------------------------------------------------- <br /> 's Name --- ---------------I <br /> -------------------------------------License <br /> Installation will serve. Re Phoned-.; <br /> Residence 21-epartment House°] Commercial oTraller Court :7y-r <br /> Motel El Other -------------------------------------------- <br /> Number of living units: <br /> ----/----- Number of bedrooms �------Garbage Grinder Lot Size ofc"W711-1 <br /> Water Supply; Public System and name ____-_____" <br /> Water <br /> Clay E] PeatLoam- ------------------------Private <br /> Character of soil to a depth of 3 feet, Sand:�� - ----------------------------------------S-a--n-d-y---------- 0 Clay Loam 0 <br /> Hardpan El Adobe 0 Fill Material ------------ If yes, type --------- "_-- __ __ <br /> (Plot <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 seepa e Pit Permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK 1'1�"low <br /> Size--- '0' Lf 9f� <br /> Capacity/4,00----- Typdft�- -.z-0------- Liquid Depth ----------------- <br /> Distance to nearest: Well MatericiaOKWZ.77- No. Compartments ------------- <br /> _63----------------- -----Foundation /40-70----------- Prop. Lin 1" <br /> 10 --------------- %A <br /> LEACHING LINE fe No. of Lines --3------------------ Length of each line.,1-9-e-------------------- Total Length <br /> -------------- - <br /> V Box -IV);�4-- Type Filter MaterialAO-CAC------Depth Filter Material /? it <br /> Distance to nearest. Well --46,3-/--------- Foundati6n I Zo / <br /> SEEPAGE PIT [ J -- - - -- - - ----------------- Property Line X G�_-"_______•----_-•--- <br /> -� ------------- �A <br /> Depth ------------- -I----- Diameter ---------------- Number .--------------------------- Rock Filled Yes No <br /> "Water.-Table Depth -'-------------- <br /> -----------------------7----------------I----Rock Size <br /> 1 Distance to nearest: Well ------------ <br /> I ------ Foundation --------------- .... Prop. Line -------------- <br /> REPAIRADDITION(Prev. Sanitation Permit# ----------1 !--�............ -------- <br /> ii ----------------- ----- --- Date <br /> Septic Tank (Specify R�quirements) ---- ----- <br /> ------------- <br /> ------- ---------------------- <br /> -----------------Dis osal Field (Specify Requirements) ------------ IX— -- -A <br /> ,I ------------------- ------------------------------------------------------------------------------------- <br /> ------------------------------------ --------------------------------------------------I/ --------------- <br /> ---------- ----------------------- ----- ---------------- ----------------------- ------ <br /> - ------------------------------------------------------------------------- ------------------------ <br /> -,A-i---------------------------------E___________ <br /> (Draw existin <br /> ,g and required adc(ition on reverse side) <br /> I hereby certify that'l hive prepared this aPpfic <br /> ,pfion and that-the' work will be done in accordance with Son Joaquin <br /> County Ordinances, Stat+ Laws, and Rules PricloRegulations of an Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the .1 / _-_ .� S <br /> "I certify that in the performance of the wo'rO for which this permit is issued, I s <br /> f t hall not em to an persoii�ih,sych manner <br /> as to become subject to Workman's Compensation laws of California.- <br /> Sign I IL -1 <br /> Signe <br /> ------ <br /> -- ------------ <br /> ------- --------------------------------------- ---------------------- Owner <br /> By <br /> ei <br /> - ---- ------- <br /> (if other than ow ------------------ ---------------- Title 4�� <br /> I i FOR EPA1tTMENT USE ONLY <br /> ,PLICATION ACCEPTED BY ------ -------------------------------------------------------------------------- DATE <br /> !LDING PERMIT ISSUED <br /> )ITIONAL COMMENTS ==-=-----DATE <br /> ------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------ <br /> ---------------------------- - --- -----------------------------------------------------• <br /> -------------------------------- <br /> - <br /> ,spection b -- -------------------------------------------------------------- <br /> - <br /> Y - ----- - --- <br /> Date -- ----- <br /> -� --------------- <br /> K7--V----------I------- <br /> SAN JOAQUINJOCAL HEALTH DISTRICT <br /> 1-'68 Rev. 5M -j r <br />