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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> •..... Permit No. .. � 1� <br /> (Complete In Triplicate) <br /> . <br /> A _ <br /> ...... Date Issued5....._.... .--........ . .. . 7 <br /> ............ This Permit Expires 1 year From Dot*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 Ordinance No. 549 and existing Rules and Regulatiortiss <br /> IOB ADDRESS/LO A ION . �.1.��.�...- . ...... �/ q ...CENSUS TRACT ....•..•.................. <br /> Owner's Name ....- .. ............................. :............-...Phone ..........,.,................:..-... <br /> Address . . .. ...-... 1.� ..,•.> v.� ..`7... ........... City .. ...........-•--...,.......................... <br /> Contractor's Name ..- .__1 �. i �•� :........License 1. .hone ......:....................... <br /> Installation will serve: Residence Q Apartment House t] Commercial ❑Trailer Court ] <br /> ' j i. Motel ❑Other - `�.�-- • -- <br /> Number of living units• :. { . Number of bedrooms Garbage Grinder Lot Size - <br /> Water Supply: Public System and name ---------.........................................................................................:....... <br /> :...Private <br /> Character of soil to a depth of 3 feetI Sand❑ ilt Q Clay ❑ Pact-o'.. _Sandy_Loam ❑ Clay loam ❑ <br /> Hardpan Adobe❑ Fill Materlal ............ If yes,type l <br /> (Plot plan, showing size of lot, location of system in relation 'to wells, buildings, etc. must be placed on reverse sl 0.1 <br /> J" <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is avoilable within 200 feet,) a <br /> PACKAGE TREATMENT SEPTIC TANK Size.` ..�.�Y..�.... .�............. Liquid Depth ....................:..... <br /> 6 <br /> ` No. Compartments Capacity .� -�?..... Type - - - - • -. Materlal F--�'•~:�,�. p ............... ...... <br /> It <br /> Distance.to nearest: Well SO../�~ oundation .......�±". _ Prop.line .... �!�... I <br /> LEACHING LINE ( No. of lines ----:- .�-.• -=-. Length of each lina...... �., ...... Total Lengthy ...��..• <br /> ' MaterialD' B ................... <br /> ( tr5 .F <br /> ri <br /> Distance,to,nearest. Well .... ` IE <br /> ��.�: Foundation :_...::-ti!• • .._: Prop"o Pro a Line `r <br /> .- ...-.:y..... Rock Filled Yes No <br /> k <br /> SEEPAGEPIT (F Depth .F' ./`�• Diameter .... Number .... <br /> Water Table Depth ............... L?-. -. ..:.. Rock Size ... .. _:-. '. ....... <br /> Distance tolnearest: Well 9 -- ...Foundation ....... Prop. Line •.. � •••� <br /> i. REPAIR/ADDITION(Prev. Sanitation Permit#'. • <br /> ...:.... Date ..... -----------------1 <br /> Septic Tank (Specify Requirements). ......... .................................................................... ......-................ <br /> t <br /> Disposal Field (Specify Requirements) .-------• _..._ . ..---_- ..... ........................... <br /> l. -------------------------------------------------------------------------------------------I...--............_-••--- <br /> i - .................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done' In accordance Mth San loagaitt <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Hem* owner.or licem <br /> l 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 /> : Signed ---I------_- •------------------- . . ..... . .....------. ----- Owner <br /> xitl - /- <br /> BY ........- •--- - -- ----------------­- -�� ....... . ...... <br /> Of other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----�'... ..Tf7 <br /> ------ •- - <br /> DATE .5.. . r�� •---_------ <br /> BUILDING PERMIT ISSUED ..---._..:-t:..:...... _•..�..�.....'-�---•----- ----------•-•--• :.DATE. .. ._. ' <br /> ADDITIONAL COMMENTS .............!..---- ... ............................. <br /> .................................. ........ <br /> ----------------------- <br /> ----- ----- ---••- -•---- --....-. <br /> ---------------•-- ---... <br /> Final Inspection by: . Date .S'._ <br /> l' 13 2!; 1- v• SAN IOAQIiIN LOCAL HEALTH DISTRICT 8/74 3M <br /> l <br />