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FOR OFFICE USE: pPLICATION FOR SANITATION PER+.-A permit No. <br /> -- ----- <br /> -- ---------- [Complete in Triplicate) f 2/ <br /> Date Issue -" -----•-----•----• <br /> ---- <br /> - ---- --------------- This Permit Expires 1 Year From Date Issued <br /> hereby made to the San Joaquin Local Health District for a per. 9 construct and install the wark herein <br /> Application is y �n Rules and Regulations- <br /> Application is made in compliance with Co <br /> Or a�No. 49 an � g <br /> described. This app � Ly' <br /> � � - ------ '� - CENSUS TRACT <br /> - ----- --------- - -- <br /> JOB ADDRESS/LOCATIONl Phone <br /> Owner's Name ! ` - --------- City L- — -`-- ---- --�- <br /> y�. ?� - � <br /> Address �� �� f Phone 7-_------ <br /> ---------.License # f� <br /> Contractor's Name ------- ---- ---- " <br /> ------- ------- <br /> Residence ❑Apartment House❑ Commercial []Trailer Court ',❑ <br /> Installation will serve: <br /> Motel [I Other ------------------------------------------- <br /> Grinder <br /> --- ----- ----- ----------- L}o�� ------------- � <br /> ---- -- - - -- <br /> Lot Size <br /> Number of living units:-----"------ Number of bedrooms ------------Garbage Grinder ------- -- Private <br /> - ----•----------- <br /> Water Supply: Public System and name ------------------------------------ <br /> ----------------------- Clay peat Fl. "sandy Loam ❑ Clay Loam C3Character of soil to a depth of 3 feet: Sand'❑ Silt p Y <br /> Hardpan ❑ Adobe Fill Material -------- --- If Yes,type "---------- <br /> st be placed on reverse side.) <br /> (Plot plan, showing size of lot, location of system in relation to wells, <br /> buildings, etc. mu <br /> 9 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if�public sewe s a2ailable within 200 feet, <br /> y / Liquid Depth ----- <br /> ---------------------- <br /> TX <br /> "---�--•.".-.."..".-- <br /> SEPTVCTANK [ ] Size 1C /-----�-- --- t/ p <br /> PACKAGE TREATMENT / -- No. Compartments -- ---- <br /> Capacity/_- Material <br /> 0 Q 4_.--. Type �" � <br /> '7 ' ' c7�---------- Prop. Line (- <br /> Distance to nearest: Well -"�+- d---- Foundation _"_ -- <br /> LEACHING LUNE [ ] <br /> No. of Lines -"-- Length of each line-"__._-"_-"----------- ---- Total Length ""---------•----•-----•--•-- - <br /> - ------------------Depth FVlter Materia( -------------------------------------------- <br /> 'D' <br /> ----------- ----------------------...----- <br /> 'D' Box ------------ Type Filter Materia( Line <br /> Property -------•----•--•-•------ <br /> Distance to nearest: Well ....................... foundation - ` Rock Filled Yes No 0� <br /> Co - <br /> SEEP� A� Depth Diameter Number „ ,� <br /> ------------Rock Size -�-�".Z-• ----- ----•- <br /> Water Table Depth -------�o-- ----- ---- r ' <br /> G .-------•-Foundation - -- ---- ------- <br /> Prop. Line - ------ ------------ <br /> -------•-------- <br /> Distance to nearest: Well -----" - ) <br /> ' ---------------------------------------- -- Date ----•--•- --•--•--"-•-------- <br /> REPAIRf ADDITION(Prev. Sanitation Permit# -------------------------------- <br /> ZLI� ------- <br /> Tank (Specify Requirements) ------------------- --------------- <br /> ecif Requirements) <br /> --------------------------------------- - <br /> Disposal Field (Specify <br /> P-------- -------------------------------------------------- <br /> - = -------- <br /> -------------------------- - - ------ <br /> . ----------------- <br /> ---------------- - _ ______ - <br /> ------ ----- ""--- "�- --" (Draw existing and required addition on reverse sie <br /> ance <br /> I hereby certify that 1 have prepared this application and th°t the work will be done in actO <br /> the San Joaquin Local Health D strcf. Home towner or l ceh Son n <br /> Y <br /> County Ordinances, State Laws, and Rules and Regulations Of <br /> sed agents signature certifies the following: ermit is issued, 1 shall not employ any person in such manner <br /> "l certify that in the performance of the work for which this p <br /> as to bee rt}e s1r_ _ <br /> j�t to /or an's Compen ion laws of California." <br /> (f Owner <br /> Signed ---------1' <br /> _ ----------- Title ----- -- -- ---- ----- ----- ------------------ --- <br /> -- -------------- -- <br /> By <br /> (If----other than owner} <br /> Vi: R DEPARTMEN USE ONLY <br /> --- - ---:--/------ --' DATE --- -- ----- <br /> ---------------------- <br /> APPLICATION ACCEPTED BY __�,- _."-- -_- -- ---- - - --- "--" ."_""_-""_-"_-_" <br /> ----- DATE -------------- --------------- <br /> ---------------------- ---------------- <br /> BUILDING PERMIT ISSUED ----------- ------------ - ----- ----------- -- -- --- <br /> ADDITIONAL COMMENTS ---------- <br /> -- --- -------------------------------- _ <br /> ------------------------------------------ .- .---- -- -- � -- <br /> -- <br /> - <br /> ----- ------- --- ---- <br /> ------------------ ---------Date <br /> Final Inspection by: --------- - - <br /> ------------------------- <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> >_- H. 9 1-'68 Rev. 5M <br />