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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit Na. <br /> r <br />...............�_-........ ----._--_:......._..--•-- u <br /> (Complete in Triplicate) s••••••-_.. � <br /> r <br />................••-•--------._.._..... _............ _ <br /> This Permit 1 Year From Date Date'issued ..�...'�,5. <br />•••..-_--'............................................... <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> . scribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .... 3 . _. 57`al�c.... ......................:................................CENSUS TRACT .......................... <br /> Owner's Name ... ------ ............................. .........'......................Phone ....f-. <br /> Address ..--o�33d�_3�.aS�o�C----.•�� ....................................................City ........... .�............... ...... <br /> Contractor's Name .License # ........... ............ Phone .............................. <br /> Installation will serve: Residence R)Apartment House f] Commercial❑Trailer Court 0 <br /> Motel E3 Other , .�.�4v.. <br /> ....... <br /> Number of living units:_...j.____ Number of bedrooms . ,33� Garbage Grinder ..../....... Lot Size -••••--•-•-•� <br /> Water Supply: Public System and name .............................Private ❑ <br /> Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay X /Peat❑ �. ..Sondy Loam Clay Loam ❑ <br /> Hardpan❑ Adobe-E3 4111 Material .`_ *..:.,lf yes,type ............... ............ YYY <br /> i <br /> fR, ,F .. <br /> (Piot plan, showing size of lot, location of,system-in relafion to wells, buildings, etc. must be placed on reverse side.) `C <br /> , t � <br /> NEW INSTALLATION: (No septic tank r seepoge..pit.-permitted-If public s we er is available w ,) <br /> ithin 200 feet <br /> ,)4 <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC j ,xt t A 1•u6 Size....... ..................,.. :.......... Liquid. Depth ....---................... <br /> Capacity/;kgAr--� <br /> =i ...... Type - Mater:al----------`. '-..eNo. Compartments <br /> .... <br /> .....I............. <br /> ll , .... ...--- . ........a lonDistance to -nearest: WeerLine . <br /> LEACHING LINE [. ] No. of Lines ... .................)Length of each line------—VA __.. Total Length .....-•------.. <br /> • i � / � x �x tib•... <br /> 'D' Box ..__._t-._. Type Filter Material ...................Depth.:Fiiter�Materiat .. .............................. <br /> Distan to nearest; Weit .... .................. <br /> . ..........`..)Foundation ... r._.....-. Property Line ----.................... _ <br /> 4i. <br /> SEEPAGE PIT [ Depth r-, _`.............. Diameter ---`�'�`�-- Number .............. •- .... ... Rask Filled Yes ❑ No (3 <br /> a <br /> Water Table Depth ..:_Rack Size f <br /> .............................•. <br /> Distance toinearest:-Well -----........-----------------_..`:::.Foundation ................ Prop. Line .......... � <br /> REPAIR/ADDITION(Prev. Sonitation,P•ermit#:'.---=---:--------------•-----..._...__._ Date` �.-•- -_�.. •-••-•-•---.....--} <br /> /- a d <br /> Septic Tank (Specify Requirements) _ car" .. �,� _ �.. /�� .,.. ................ <br /> Disposal Field (Specify Requiremenfis) ft. Le" <br /> 40j------------------------------------------------_ ...... <br /> l <br /> i {Draw existing and required addition on reverse-side)—-, <br />'j i hereby certify that V have pirepared this application and that the work'-will be done in accordance k with San Joaquin <br /> County Ordinances, State Laws, and Rules and"Regulations of the San Joaquin Local Health,District. Houle owner or llcen- <br /> sed agent§ signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any perion in such manner <br /> as to becom su (e o W rk a s Co pensation laws of California." i } <br /> A <br /> Signed ----------_.........................••. <br /> Owner <br /> . ... -� <br /> Title -_-----..._ , - --------- <br /> (If other than owner) ; <br /> A—OR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY i_. <br /> DATIr �_ .. ........ --------- <br /> BUILDING' PERMIT ISSUED 1------ .-.,..-..DATE -- .-----.--".-- <br /> ADDITIONAL COMMENTS . ;" <br /> ... L - <br /> ..... _-----....... --••------------------ ........ ------------- <br /> -��¢� -yam_ .� _�._. <br /> Fina! Inspection by: . r ----------------------------------------1.: ----------••- --------.------..----....._..._Date <br /> �.�.��f..�.......... <br /> " EH 13 .2L 1=68 ' 1kv. 5 SAN JOAQUIN LOCAL"HEALTH DISTRICT 8/7b 3M <br />