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rUtc Urricx Mt:s APPLICATION FOR SANITATION PERMIT <br /> -77-i,� <br /> r.. Permit No. <br /> (Compfete in Triplicate] . . . <br /> 3—.. . <br /> This Permit Expires 1 Year from Date Issued 'Date Issued �"' - <br /> 22 <br /> Appllcatlon 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 Regulationse <br /> JOB Owners Name OCATION �............CENSUS TRACT ......................... <br /> ...... ........................................ . ........................... _Phone .............. <br /> Address ..............._...s:� Oy�,�45 City . <br /> Contractor's Name .......................................Ucense# , .. Phone. :r .. <br /> installation will serves Residence P Apartment House❑ Commercial OTraller Court 0 <br /> Motel❑Other............................................ .� <br /> Number of living Unitas-..1.-_.--- Number of bedroom& Garbage Grinder Lot Sire ................................ <br /> Water Supply: Public System and name ....................... .,.................... .-,...»..........................................Priirats j- <br /> i I <br /> Character of soil to.a depth of 3 feet: Sand.E3 Sift❑--.'Clay Q Peat j] Sandy Loom JR day Loam ❑ <br /> Hardpan Q Adobe 0 Fill Material ............If yes,type............... .......... <br /> . F � <br /> . <br /> !Plot plan, showing size of lot, ovation of system In relation to wells, buildings, etc.must be placed on reverse side.f <br /> NEW INSTALLATIONi�vjko.septic tank for,seepage pit permitted If public sewer is available within 200 feet) <br /> PACKAGE-TREATMENT ['] —SEPTIC TANK� ] _.._y._..� Size....�K..l,.��..�................. Liquid Depth :::�`�r�....-;� <br /> �-. ••i 1,a' < � - <br /> Capacit�r` :? `TYpeM. i `. .TMatertal...................... No. Compartments ...................... <br /> Distance'to near at wBli' . .�..�....... .............Foundation .. . .......... Prop Line: ...:. <br /> LEACHING-LINE a '[ D '�No:of-Lines �................ Length of each line....: f1 p............ Total Length Z-260............. <br /> 'D' Box .. .f.. Yype F�Ire�.Material.� t� .Depth Filter Malarial . . ...... '.................... <br /> Distance to n areztty Well . a.:�..... `. Foundat n`.:2J .�. .:`... Rroperty line �?.1...'... <br /> SEEPAGE PIT [ 0 Depth Diameter ......z?. Nu'mbet. ... .�'.............. Rock Filled' Ye' ❑ No <br /> Water Table Depth ...........••.. , :...............Rock Simi ..........:................... j <br /> Distance to nearest: Weil ...............,.... ..... . ......Foundation '::......... Prop. Line#. ................ <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............. .......................... Date ......, ..._ � <br /> Septic Tank ISpecify Requirertsentsl .............. ..... ...... ........ ..............................- ..... ._........ .... <br /> t �. ....�. ........ <br /> ...- ----. .... . <br /> ....' _ .. ......,.—r...... <br /> Disposal Fielci (Specify Requirements) ..........................................._.. ...... ..................... .......................................' <br /> + •I _ + a . <br /> I <br /> ..................:................................................:.........................•--•--....._........................... .............,................................................. <br /> (Draw existing.and-required.addition an reverse;tilde). + f <br /> 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 Rulesrand­Regulations of the San Joaquin Local'Houlth District. Home owner or liven, <br /> 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 1n such manner <br /> as to become subject to r an's Compensation laws of California." <br /> i jned 4 t <br /> f <br /> g ••-- -•......................... Owner <br /> BY ----------- ....... •--.._...•--•------•.................................. ..._ yitle .......................................... .. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY. - <br /> APPLICATION ACCEPTED BY ........-----•... ••-- •---•------... -:a. ....... `. :...p�... .z.s .` 7-............., <br /> DATE <br /> BUILDING PERMIT ISSUED ^....__..- �,r ,'� .. , <br /> ... <br /> ADDITIONAL°COMMENTS ......... � --------- t--- ....../. .. _.:�....... �. � DA .................... :.�........ <br /> ........................................�.... �............�...._.................. ................... <br /> .................................................. <br /> ..... ........... <br /> Final Inspection by: ... ... ----- - ...Date . <br /> ..........- .7-_� <br /> 13 2h 1-68 v. [ S N <br /> JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> 1 <br />