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5b!Z OFFICt 0SE- APPLICATION 'FOR`SANITATION PERMIT <br /> aPermit N64 ---------------- <br /> `�(6m6 fete in"Triplicte <br /> ------------------- ----------- ----- - . - '- - <br /> ------ J, " Date Issued - 71 <br /> --------------- This Permit Expires <br /> -Y <br /> 1 ear'From D6ieJ1ssued <br /> -------------------- --------------------- <br /> 71� <br /> Application is herel�-y 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 nd -Px1st1nh1RuIes and Regulations. <br /> r <br /> -_CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOC/ATI ------- --- ----- ----- - --- -------- - ------ --- <br /> oel <br /> Owner's Name -------- - -- ---------- ---------- -- - ------- -- ----- ------- ----- ------------ ------------------------Phone - -- ----- <br /> .. ... it C5;K <br /> ---------- ---------- <br /> Address ----------------- - ----- <br /> ------------------------------- <br /> Coniractor's Name --,/�Phone <br /> ----------------License ------- <br /> --- ------ ------ <br /> Installation will serve- Residence*Apartment H use,E] Commercial:[-]Trailer Court <br /> Motel F Other ----- <br /> -------------------- <br /> S- <br /> 9?-G <br /> Number of living units:--.{------ Number of beArooms77--' - .,- arba'g-e' Grinder ------ \'io Size <br /> ------- <br /> -------------- <br /> ❑ <br /> Water Supply: Public System and name ------ ------Q--1-C--C�T --------------------------- -----Private <br /> Character of soil to a depth of 3 feet: Sand'o Silt C] Clay E] Peat E] Sandy Loaml-Lk: Clay Loom EJ <br /> Hardpan F1 Ad be 'E] Fill Material ---------- If yes,type ----------------- ---------- <br /> P <br /> (Plot plan, showing size of lot, location of system in relation to wells: buildings, <br /> ildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avoilableI'within 200,fiet,) <br /> P A-CKAGE TREATMENT f ] SEPTIC TANK` SiZT--4Liquid De'pt'h --- --------- <br /> A--- - <br /> Capacity/,;&C/-e Type 1�01&-----�' Material- --- No. Compartments ---1 ---- -------- <br /> Distance to nearest: Well _f--_______._________Foundation .... ------- Prop:,Line ------- <br /> LUCHING LINE X No. of Lines ........X------------ Length of each line ----------- Total Length -e-114 '�.. ------- <br /> '44 <br /> 'D' Box,.--Z---- Type Filter Material le&C-A6.....Depth Filter Material ---- ----------------------- <br /> Distance to nearest: -Foundation ----------" prty Line --------------- <br /> SEEPAGE PIT Depth 671 -1 ------- Diameter ---"."Number ---------- ,7-------------- Rock Filled Yes E*1 No 0 <br /> Water Table Depth -------- '---------------• ----------Rock Size ---- ----------------------- <br /> Distance to nearest: Well ......, <br /> �J-o-----------------------Foundation ---- ----- Prop. Line .....IS ..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------.--------------------------1 <br /> 'Septic <br /> ------------------------------ -- <br /> 'Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ -------- <br /> DisposalField (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------- -------------------------------------- ---------- ----------- <br /> (Draw existing and required addition on reverse side) <br /> Chereby 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 Son 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.4 such manner <br /> as to.'become subject to Workman's Compensation laws of California." <br /> Signed ................. --------------------------------------------------- ------------ Owner <br /> �7- <br /> By ------------------I" <br /> -------- ;Title ----- ----- ------------------ <br /> --- -- ----- <br /> (If other than owner) <br /> F A&T USE ONLY <br /> -APPCICATION.,ACCEPTED,BY------------- -----------------DATE ---------- <br /> BUILDING PERMIT ISSUED -------- - N- ------- - ------ --------------------------- --------------D"ATE -- <br /> ------- - --------------------------------- <br /> ADDITIONALCOMMENTS ------- -------- ----------------- ------- -- ---------- --------------------------- ------------ --------------------------------- ---------------- <br /> ------------------------------------------------ ------ --------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------- --- - <br /> --------Ir--------------------- --------------------------------------------------------------------------------------------------- <br /> --------- ------------------- ------- -- ---- -- ------- ------------------------------------- <br /> ------------------ <br /> Date ---------- ------------ <br /> Final Inspection by.. �------- -------------------------- ------------ <br /> ----------- -- ---Z <br /> ---------- <br /> E. H. .9 1-'68 Rev. 5M SAN J0 U N LOCAL HEALTH DISTRICT <br />