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A <br /> FOR OFFICE USE: AP LICATION FOR SANITATION PERMIT <br /> --- •---------- - --- <br /> ---- t 5 <br /> (Complete in Triplicate) Permit No: <br /> ---- ------- --A�A- <br /> Date Issued _4 = `S. --� <br /> -------------- _- .- }� is Permit Ex ires 1 Year From Date Issued <br /> 6., <br /> Application is hereby made to the San Joaquin Local Health`District for a per to construct and install the work herein <br /> described. This application is made in com 'once with County Qrdinance No. 54 and Ifisting Rules and Regulations: <br /> JOB ADDRESS/LOC TION ___. _ _ �,_.__ /.t _ __ '� <br /> 9 � � --- - a - --._C NSUS TRACT ----------- �------------ <br /> Owner's Name -- ----------------- - � Phone <br /> Address --- ------ Y -----/- N----------------- City -------- ------------------------------------------- ... <br /> ZP. `�C -----------.License # PhoneContractor's Name __ - _ _ _._ _____ <br /> Installation will serve: Residence, Apartment House Commercial ❑Trailer Court ❑ <br /> Motel Other -------------------------------------------- <br /> Number <br /> ------------------------------------------Number of living units:----'------ Number of bedrooms __ .-___Garbage Grinder ---(------- Lot Size 7- 77'4N------------------ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------•-----------------------------Private, <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam <br /> Hardpan Adobe ❑ Fill Material'------ --- l'f 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 seepage pit permitted if PLIblic sewer is avgiloble within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK[ I Size---- _.6_0----- --------- Liquid Depth ________________ <br /> Capacity -------------------- Type -------------------- Material__ No. Compartments_.......... <br /> Distance to nearest: Well ____________________________________Foundation - -------------------- Prop. Line ---------- ._:------- <br /> LEACHING LINE [ ] No. of Lines ---------------- Length of each line-.-,1D 4 Total Length v l__ ............ <br /> D' Box ------------ Type Filter Material Depth Filter Material ___________________________________________ <br /> (Q Distance to nearest: Well _________________ ______ Foundation _________---_-._------ - Property Line _________--...__-_-__. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------- <br /> Distance to nearest: Well ---_----_______________________________Foundation -------------------- Prop. Line _____---..---_--__-._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----________________-_--__________] <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------ ---------------------------- •........... <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•------------- <br /> --------------------------------------------------------------------------------------------------------------------------- -----------------------------------=--------------•--------- <br /> i (Draw existing and required addition on reverse side) <br /> I 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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which is permit is issued, I shall not employ any person in such manner <br /> as to beta esu to orkmsatio law of California." <br /> Signed 4C a---- �� Owner <br /> BY ------------------------------------------------------------------------------------- ----------- Title -------------------------------- -- ----- ------------------ <br /> (If other than owner)- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... __ - ___________________________________ ( '' - --- <br /> BUILDING PERMIT ISSUED _______________________ _____________ ----DATE�� <br /> --- -- ---------------------------------------------------- <br /> ----------------------- <br /> ADDITIONAL COMMENTS --------------- - - ---------------------------------------------------------------------=--------------------- <br /> ------------------- ---------------------------------------------------------------------------------------------- ----=------- ---- -------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------- ----------------------------------------------- <br /> -- ------------ ---- <br /> - s� -- ---- <br /> _;aFinal Inspection by: _._-- ._ -----.Date -------------------- - '"'"` <br /> == <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />