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FOUR OFF1j:E USE: y <br /> APPLICATION FOR SANITATION PERMIT permit No. 76 X55 ' <br /> -,.�. , <br /> - ------------------------------------------ ---------- <br /> _ iComplete�in Triplicate} <br /> �,� ,Ci <br /> Date Issued ._ <br /> i This Permit Expires 1 Year From Date issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> in com li nce with County OrdinSly No. 5491and existing Rules and Regulations: <br /> described. This ap Flicatio s +�1i fJ <br /> �Vf � -------- �-�-_�-------- �+---•--- -`- ---- CENSUS TRACT ��---•--- <br /> JOB ADDRESS/LOCATION .---°=-------------------,-+-- -- <br /> -------. R_/1{fl --------M-r7 _ Phone <br /> Owner's Name <br /> - -- -- ---- -- - <br /> "- -------.__: Cit - - --- --------------------------------------- <br /> Address <br /> - - ---- <br /> --------- <br /> Address ---------------------------------[---------------------------------------------------- <br /> Phone, <br /> -"License# ------- <br /> Contrar_tor's Name ---------- -- ----------------------------- --- <br /> t i <br /> Installation will serve: I Residence ❑Apartment House❑ Commercial:❑Trailer Court !❑ <br /> Motel ❑Other --------------- ------------ ------- ---- <br /> „, ------------- <br /> ------ -------- <br /> ___+___ Number of bedrooms __�--_---Garbage'Grinder =f13'_ Lot Size _.��----- <br /> Number of living units:._. - <br /> 'N Private ❑ <br /> Water Supply: Public System and name ------/"_T ROP-1 = L_-_ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam "Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ :Fill Material ._ _ _ =_ IfEyes,type _-___---------- ---- <br /> i <br /> buildings, i.efic. must be placed on reverse side.) <br /> (Plot plan, showing size of [ot, location of system in relation to wells, ;r tLVI <br /> NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,) it <br /> Size---- �. C.i�%---------------------­1Liquid Depth __ '------------.----- <br /> PACKAGE TREATMENT [ SEPTIC TANK [G _ - - t <br /> Yp `G' <br /> Capacity .� - ---- T e Material No. Compartments -- -----------•- <br /> �. Foundation . -------- Prop. Line ------ ----- ------- <br /> stance to nearest: Well - _______ -------------- f <br /> = <br /> LEACHING LINE 'of Lines _-_-� -------- - Length of each line-----70---- <br /> C� <br /> ----------- Total Length <br /> ---------- <br /> 'D, Box Type Filter Material `s----Depth Filter Material ___-._�__ _ _-- <br /> --•------ <br /> - �'_ Property Line ----- --------------- <br /> Distance to nearest: Well ___ Foundation <br /> I ` <br /> 1 <br /> SEEPAGE PIT [ ] Depth Diameter ---------=------ Number _____ __------1------------- Rock Filled Yes ❑ o <br /> ------------------ <br /> Water Table Depth Rock Size _ ..__------------------ - <br /> ---------------------- <br /> Distance to nearest; Well ----------------------------------,--- <br /> Foundation <br /> -------------------- Prop. Line ----------•---------•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------- L =.` :;Ddte------------------------------------ <br /> i <br /> Septic Tank (Specify Requirements) ----------------------------------------------------+-h=.---------------- ------• ----- <br /> Disposal Field (Specify Requirements) ------------ l ----------------------------------------------------------------- <br /> 1 <br /> I ------'---- --------------------- _ <br /> T� <br /> --------- - -----------------------------4------------------------------------- ---------------------------------------- <br /> ------------------------------------------- _ <br /> (Drove existing and requiredaddition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the' work will be kdone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of'the San IJoaquin 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 sub) to Workmn's Compensation"laws of California." i <br /> • Owner-µ•- <br /> ---------- Title --------------------=----------------------------------------- <br /> (If other than owner) 3 <br /> "f AOR DEPARTMENT USE ONLY <br /> 011 <br /> APPLICATION ACCEPTED BY .__-- �----- ---Z�C-f�- <br /> ------------------ <br /> DATE - L -----'----- <br /> ��-•��----�� ----- ----� --------DATE - ---------•----------------------------- <br /> BUILDINGPERMIT ISSUED ----'----------------------------------------------- ---'-A`-----='------------------------ <br /> ADDITIONAL COMMENTS ---------- --------- ------------------------- ------:------------- - <br /> ---------------------------------------------------------- <br /> �. - .-.... . T <br /> ' <br /> ._ <br /> -:-------------- -- -- -- <br /> --------- ------------ -- <br /> - bate ��----------- <br /> Final fns ection b <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />