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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.�72--__ __6______ <br />-- --------• - (Complete in Triplicate) <br /> �'r -4 <br /> -1 <br /> l--_ Date Issued -'.-�--.---�-L <br /> ------ --------------------------- <br /> This,.Permit_Expires 1 Year From Date Issued <br /> Application is hereby made #o the San Joaquin Locdl'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 Regulations: <br /> r, <br /> --CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATI - �----- -- ------------------------------------ <br /> Phone <br /> Owner's Name t � ----------- -_4 ---- -------- City <br /> ) -------- ----------T--�--�--x-�--t----(-�---- <br /> Address _ -` _ <br /> Contractor's Name --- '-. J --------- -------- -------- ------ - <br /> =• <br /> q.. <br /> r. <br /> --- ----------License # - --- ------ Phone <br /> Installation will serve: Residence artmen# House❑ Commercial "❑Trailer Court 0 <br /> Motel ❑Other -- ------------------------------- --------- f <br /> Number of living Number of b drooms --_ Garbage Grinder --- -------- Lot Size ------ --- ----------------------- <br /> units:___.:_______ _ - <br /> J. Private 11Water Supply: Public System and name ________ W C7 1 ------------------- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F-1Clay ❑ Peat E] Sandy.Loam ❑ Clay Loam:❑ <br /> s ' <br /> Hardpan ❑ Adobe'0—f4I}Nlaterial ------------ If yes,type --_------------------------ <br /> (Plot plan, showing size -of lot, location of system in relation to wells, buildings, etc. must be placed on reverse velri< side.) 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 20efeet-- <br /> - -Li uid Depth ___._ <br /> PACKAGE TREATMENT 111] SEPTIC TANK.j ] Size------------------------------------------------ q p <br /> I ---- Material-------------.--------- No. Compartments --------•--------• -- <br /> Ca oatY --------- Type <br /> Distance <br /> to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line -------•-------_---_ <br /> LEACHING LINEj ] No. of Lines -----=------------------ Length of each line---------------------------- Total Length ----------- ----------­---- <br /> "� �•---�--•�-,µ— -"F--- '- - Depth Filter Material <br /> D, Box ----------- TYpe Filter Material p <br /> - CDis#ante to nearest: Well ------------------------ Foundation --------- -------------- Property Line --------•---------•=---- <br /> d No <br /> SEEPAGE PIT [ .] Depth -------------------- Diameter -------- ------- Number ---------- ------------- __ Rock Filled Yes ❑ <br /> Water Table Depth ------- -------------------•------ Rock Size <br /> Distance to nearest: Well -----------------------------------------------.Foundation -------------- ----- Prop. Line -------•----- --•----- $. <br /> REPAIR/ADDITION(Prev. Sanitation Permit°# ------------------------ --------- -------- Date ---------------- ) <br /> ---- ---------- --------- - ... <br /> Septic Tank (Specify Requirements) -------- - - ----�---- - <br /> ------------ l <br /> --- ---•----------- <br /> Disposal Field (Specify Require ts) - /t f «r- -------- <br /> r ------------ ------------------------------- <br /> F/_ ---/-a - -------- -- ------------------------------------------------ <br /> ________ <br /> - - ---------------------------------------------------- - -------- --- ------- - <br /> - ------- <br /> G (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 this permit is .issued, I shall not employ any person in such manner <br /> as to become su 'ec to Wor n's C m ensation,,laws of California." <br /> -_ UC" _ Owner <br /> Signed ----- ,@J---- -=- --- - ----------- ------- ----------•------------ <br /> • Title - ------------------------------- -------- ---------- <br /> ------ --------------------------------------- <br /> (If other than owner) <br /> F PARTMENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY ----- -- ------------------------ DATE <br /> - ----- - - - -- -- - ---- - -------------------------- <br /> 13U[LDING PERMIT ISSUED - DATE - ---------- --------------- ---- ----- - <br /> W, - <br /> --------- <br /> ____. <br /> ADDITIONALC MENTS = -- ------------- ------------------------------------------------------------••------------- <br /> I <br /> � r <br /> �` - <br /> �: - --= r i�'1-- - � �--- -- ------ ----------- ----- <br /> ,Date -----=�/-�f�-�-u'-•------- <br /> Final Inspection by: ____ <br /> SAN JOAQUINyLOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />