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FOR OFFICE USE:,, --y"" APPLICATION FOR SANITATION PERMIT- Permit No. 4 cP3,' <br /> ------- ------- ¢ (Complete in Triplicate) <br /> Date Issues] =/7_-�& <br /> ------------------ -------------------------------- <br /> This'Permit Expires 1 Year From Date Issue <br /> e work herein <br />,., <br /> Application is hereby made lso ode 9n co Alliance with Counealth Dtytrict for-a Ordinance permit <br /> and existing RulestalndhRegula#ons.. <br /> described. This application <br /> t (0-----•---"---. <br /> ---------/`L®-------- ----------------- -CENSUS TRACT <br /> JOB ADDRESS/LOCATION`._ �� f <br /> hone 8- . <br /> ` � -AIL -------- <br /> Owner's Name -- ---,---.-_ <br /> 14 1 1.2 -------------------- City -_F$040�..Q------ <br /> Address ---------- "--�-, 57------ - <br /> t -----License # ------ ------- Phone -_1 VWy_C----------- <br /> Contractor's <br /> -..------ <br /> Contractor shame _-."_.>�-i����---- ---"4Apartment <br /> - " <br /> ------------------------ <br /> Installation will server Residence House❑ Commercial ❑Trailer Court ❑ <br /> MoteldQther ----------------------------------------- <br /> Number of living units:- --L- Number of'bedrooms __ ---Garbage Grinder ------------ <br /> Lot Size private <br /> k�; <br /> Dr <br /> Wafter Supply: Public System and name ------- ------------- - - _ <br /> t��:; <br /> Charade of soil-to a depth of-3 f t' 'Sarid`U _-Silt❑ '" Clay'❑ Peat❑x Sandy Loam Clay Coam [ �-� <br /> '" Q If es. , e ---------- <br /> "' Hardpan0" Adobe ❑ Fill Material + y tYp <br /> r t yi5 1 y ) •V <br /> (Plot plan, showing size`of�ott,, location of system in relation ,to' wells, <br /> buildings, .etc. must be placed on reverse side.) \ <br /> f NEW IN5TALLATION:-f�{No sept; tank or Qp4ge-�it permitted .if public sewer is�ui1a),le within 2d0 feet,) <br /> "' .. _..�rSize --_- T ��:.: Liquid Depth -- ------- ------ <br /> PACKAGE TREATMENT { a SEPTIC TANK[ }- \ <br /> ` Ca acit Type ------------------- <br /> Material---------------------• No. Compartments ----------------•----- <br /> T]i lance to nearest Wel! ""- , - ---- - -- - <br /> Foundation - -------- Prop. Line --•--- <br /> I ; ....� "" Tota! Length .�'� _ <br /> LEACHING LINE [ ] N'o. of Lines -- -------3-------" Length of each line-----------#----- <br /> -- i -; �'si `pe th :Filter Material _.. _---------- <br /> 'D <br /> - " ' --------'` ---- <br /> ;G-,:,-__,»Ya� 'D' Box - -- = Type <br /> Filter Materia P u <br /> •- Distance #a nearestt.We --------------------- <br /> 4 <br /> - _ Foundation -.- ------------ -- Property Line ------------------------ <br /> -T <br /> "-"-• --------- <br /> ;V ,.. Number t " <br /> De the I Diameter - -- ---- ---- Rock Fllted—Yes°❑ Na <br /> SEEPAGE PIT ;.. [ l p <br /> Water Table Depth---- Rock-Size ----------- -------------------- <br /> Water Table <br /> Line - <br /> -- Foundation ------------------• <br /> r.. - ... .�.. Distance to nearest: Wel <br /> -------------------- <br /> rDate-x --------------------------- <br /> REPAIRfADDtTION(Prev. Sanitation Permit# -.-------..._.�,-_�;,�.:---- <br /> -- �--- - <br /> ------) <br /> 1 :`_ .. - ------------------ :----- ---------- ------ 1 Q <br /> Septic Tank (Specify Requirements) -, _='- r I( X j <br /> i - 10-+-----�----------- y <br /> t Disposal Field (Specifyquirements) D ---------------- ------------------------------------- <br /> A9C-- ---� _ ., ..,o <br /> M <br /> tT' XLI 1� .� _ _ = --------- <br /> 6_ � • <br /> i <br /> --- --- ---- --- --- <br /> ---------------------------------------------------- <br /> --------------- � (Draw existing and required addition on reverse si � ...�_.._,..�. ��� <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 /> k for which this permit is issued, I shall not employ any person in such <br /> "I certify that in the performance of the wormanner <br /> as to become subject to V6r&an's Compensation laws of California." <br /> �--- ----------- Owner <br /> Signed " - - - - - ----�1--�-�---�-- ----- --- - � --- <br /> f ' - -------------------- <br /> + -- ---- ---------- Title -------- ------- --------- --- --- - -- <br /> - f ----- -------------------------- ------ - <br /> (If other than owner) <br /> R FOR DEPARTMENT USE ONLY <br /> - DATE -- - _ --- <br /> APPLICATION ACCEPTED !BY,:I� �C �_ � ----- -- �- - �-------------------= <br /> _ ----- -------�-•_ --- <br /> BUILDING-PER1V1'IT'ISSIJE6 """t----- - <br /> --- --- --- - .y <br /> ADDITIONAL COMMENTS ------1--------------- T ._ � r -.--—'.�--- " `"'�' '='--------- <br /> - -- <br /> 7-- <br /> ---------------------- <br /> --------- <br /> -------- <br /> - ----- ----- -- -- _ _ _pate �3 <br /> -- - <br /> Final Inspectio ' <br /> A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. <br /> H. 4 1-'68 Rev. 5M 1 �s ,.; ;,;• <br />