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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ............. <br /> (Complete in Triplicate) Permit No. ...7! - ...... <br /> IIThis Permit Expires I Year From Dote Issued Date Issued - ~:. . . .�..... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> dework h�ein <br /> scribed. This application is made in compliance with County Ordinance No. 549 a IT ex t'n Rul nMeula ns: <br /> JOB ADDRESS/LOCATION <br /> t---------------------------------------CENSUS TRACT <br /> Owner's Name / n /.1Y .. y ........................."`� . _ �.._ <br /> Address ./,P,f7s�- .C�. Phone � . ._ .,, .7..... <br /> ....................... City -.t-: tof/t- Q14- .......... <br /> Contractor's Name .............. !�...... :....-.License # ::.. Phone <br /> - -------••-•- ------------------- .............,................. <br /> . .............. <br /> Installation will serve: i Residence�Apartment House 0 Commercial ❑Trailer Court i❑ <br /> Motel ❑Other„—:=-------.........I_.................. <br /> Number of living units:_u - Number of bedrooms ,,` . `.Garba eYGrinder ............ Lot Size . .�/ -•��7 � •.--.•• <br /> Water Supply. Public System and name .�,� till <br /> Private <br /> Character of soil to a depth of 3 feet; Sand❑ Silt❑ Clay ❑ 'Peg Cp Sandy Loam C1 - Clay foam ❑ <br /> Hardpan ❑ Adobe' F!N Material .. -' <br /> --..... if yes;' <br /> L <br /> {Plot plan, showing size of lot, location of. system in relation to wells,kbuildings,. etc. must be placed on reverse side.} <br /> NEW INSTALLATION: {No septic tank or seepage/pit?ermitted if public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT ! r i / <br /> [ ] SEPTIC TANK- Size-_-- ,�, -:.-.• Liquid Depth5.-- <br /> Capacity11VAa........ T t f� e� <br /> Ype Material_ _ o. Compartments' ..100 . <br /> Distance to nearest: Well ................ Foundation 7.......... --- Prop Line ._ Q <br /> i <br /> LEACHING LINE [ ] No. of Lines ................... <br /> 4 E Y <br /> Length af.each line..-- --�-----°.----.-•---- Total Length ........ <br /> 'D' Box ------ Type Filter Material ...!..:............�DDepth Filter Material /-?..................................... <br /> Distance to nearest: Well' ... �:�_.. Foundail .. N <br /> w. ------ Property Line ---...._. <br /> in <br /> SEEPAGE PIT [ j Depth --- -..... Diameter —�...._.... Number ............................ Rock Filled Yes ❑ No {] `` <br /> Water. Table Depth r--Rack Size <br /> Distance to nearest: Well ......................I.......... .....Foundation-------------------- Prop. Line'........... <br /> ---------. . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........................................ #_ Date.t.�--•-M--....------------•--••1 <br /> V, <br /> Septic Tank {Specify Requirements) -...............-• ................................ <br /> L 1 ............................• _ 7 <br /> Disposal Field (Specify - eqiM <br /> uirements) ....:�`:....... <br /> F_............ <br /> ................. <br /> --------------------....... ............ .......... -• •-. •._------.....-----•-••---..:-......-.......---............... _..............•----_. <br /> I1 (Draw existing ani quired addition on reverse si8e) <br /> I heriz6y certify that I have epared this application and that�the work will be done in accordance withl Son Joaquin <br /> County Ordinances, State Laws'rand Rules and Regulations of'fhe 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 b!n 4sulect to or an's Compensation laws of California.” <br /> Signed rZ — ----Owner <br /> BY ------------------------- <br /> ---- .....:. = ...... Title <br /> Title . <br /> {!f ather than owner} <br /> FOR DEPARTMENT USE NLY <br /> APPLICATION ACCEPTED BY . �.... --.V ..................... ..... DATE ..--....- . <br /> BUILDING PERMIT ISSUED --------•------•--... •--•-----......I..........:-••--•-••-••. ...............DATE --••....................... ............... <br /> ADDITIONAL COMMENTS ..—.!.......................................... <br /> ...........................•--•.•................_............---•-•-------• ....................I...... ... ...----------•-......•.......•-- ............ <br /> ---•--................................---- ................. .:.... .......................__...:.... <br /> F..............*............... <br /> -- - /`�^ <br /> Final inspection by: ....:...-.. Aafe _ .L.. ... <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> x t. <br /> N <br /> . _i; H..13 24 1-'68 Rev. 5M I .z `�.: _ 7/72 3 M <br />