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FOR OFFICE USE: F T <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------- --------------------------------- <br /> (Complete in Triplicate) Permit No. ______________ <br /> --------------------------------------------------- __--_ This Permit Expires 1 Year From Date Issued 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 /> described. This application is made in compli Oce with County Ordinance No. 549 and existing Rules and Regulations: <br /> 4 JOB ADDRESS/, TION aj_, L y '.... <br /> ------- ---CENSUS TRACT -----`-------------------- <br /> Owner's Name honf -[P7 ~ <br /> Address -------- -- <br /> - ---- - -- - ---- - - --- ---------------- -- ----------- City - - --------------------------------------- <br /> --------------------- - ------------- <br /> �j <br /> Contractor's Nam --__ --- -- - -------------- -----------------------License "clew-11------- Phone <br /> Installation will serve: Residence MLApartment House[] Commercial[]Trailer Court i❑ <br /> Motel ❑Other ------ ----------------------------------- <br /> Number of living units:.... _------ Number of bedrooms __�k--_-Garbage Grinder AtI0._ Lot Size -�_76-------------- <br /> Water Supply. Public System and name -------------------- -----------•--------------- ------------------•------- ----------------------- ----------Private Al <br /> Character of soil to a depth of 3 feet. . Sand:0 Silt[D Clay ❑ Peat❑ Sandy Loam [] Clay Loam [] <br /> Hardpan ❑ Adobe;K Fill Materiaf --- ------ If yes, type ----------.-_______________ <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 public sewer is available within 200 feet, <br /> PACKAGE TREATMENT rr <br /> [ l SEPTIC TANK Size--� ��.�---------------- Liquid Depth ---__-.-- <br /> -- ---- ------- <br /> Capacity Typep Material. _ - _ o. <br /> ._ _ Compartments _ ____.____... <br /> 1 7f y 5- n <br /> Distance to nearest: Well ---6�--`------------------Foundation ---------------------- Prop. Line ------------------------ <br /> LEACHING LINE <br /> [ ] No. of Lines --C-21-)____________ Length of each lineZpth <br /> _-_ _- 7 Total Length l rlJ -- ------------ <br /> ----------- <br /> _______ __ <br /> rr 9 <br /> D' Box p_�_°..1iS�Type Filter Material ��__2- Filter Material ___ __------------------- <br /> Distance <br /> __ __Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------.__.-___--:--__ <br /> SEEPAGE PIT [ ] Depth _____ ______________ Diameter ---------------- Number <br /> i <br /> - ------------ -------- Rock Filled Yes ❑ No � <br /> Water Table Depth ----------------- -------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Wel! <br /> ---------------Foundation -------------------- Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------_-----------.-_---) <br /> Septic Tank (Specify Requiremen#s) ___"-'__@.S ____--------------_ _._ <br /> ----------------------------------------------------------------------- <br /> Di sal Field (Sp[ecify Requiremf ntsl ------------------ 0-- ------- ---------- -------- --------- --------------------------------------------------------- <br /> i - --------- - ------ --------- <br /> - ---------------------------------------- - <br /> `'.,: (Drav,l x•sting and required'addition'on everse 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 i 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 ect to Wo ' an's Compei#660rays of California." <br /> Signed ----------- Owner <br /> By --------- --- CSI it <br /> Gill r�, - Ti le --:___-' = ------ <br /> (1-f- __ -------------------------- <br /> -other than owner <br /> FOR DEPARTMENT USE. ONLY r <br /> APPLICATION ACCEPTED BY - -le---C�- -------- --d— � Y�--------`:------ ------------------------ DATE -----/-�--' /b ---------- <br /> BUILDING PERMIT ISSUED -------- -- ------------- -----------------= ------------ - -------------------- - --------------DATE - ---------- <br /> ADDITIONAL COMMENTS ----------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- <br /> ---------------- -------------------------------------------------------- ------------------------------------------------------ <br /> - --------------------------- ------ <br /> - - ----- --------------- <br /> Final Inspection by; _----- ----�--- ---------------- ---- - -1 <br /> --------- --------------- ------- - -- ------ --- <br /> -- --� -���--�''� ------ ---- ------------ -------.Date ----C�-�--- -----��----�-'. ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M, <br />