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FOR OFFICE UE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> ---------------11 -R --------------- <br /> Permit No. <br /> (Complete in Triplicate) <br /> ---------------------- <br /> Date Issued <br /> _ ,� -�y <br /> -----------------------------------------7--------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a per'mit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 54q a existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> -------------------------_CENSUS TRACT <br /> 1� -;_ _�------------------- <br /> Owner's Name aV,F_Ie------------------ ------------------------------------- -------------------Phone------------------------------------- <br /> Address -------- -(Z------------------ City ------------------------ <br /> Contractor's Name --------------- <br /> A Phone <br /> _-_---__.License #/41;�, <br /> VA-—--—---------------------------- <br /> Installation will serve: -Residence E]Apartment House,E] Commercial []Trailer Court ;A— <br /> ­- 11 )P, )/r r0 <br /> .-Motel F­l Other -------------------------------------------- <br /> Number of living units:... Number of bedrooms _....Garbage Grinder _111a',Lot Size _12-4f~­.y_ ? ----------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------!--------- -----Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silto Clay E] Peat[:1 Sandy Loam E] Clay Loom 0 <br /> Hardpan ❑ Adobe;k Fill Material ------------ If yes11 <br /> !type _________._________________ <br /> (Plot plan, showing size of lot, location of system' in relation to- wells, buildings, etc.i; must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pyblic sewer is avaddable within 200 feet,) <br /> 1.0 11 / <br /> PACKAGE TREATMENT SEPTIC TANK Size-__YX _1K --------- ------- Liquid Depth _` -____.________- <br /> Capacity 1,2-0-V--- Type Material No. Compartments _4—-------- <br /> W . <br /> Distance to nearest. Well _'_A9570----------------------Foundation ---------. Prop. Line __P10 <br /> LEACHING LINE No. of Lines ____/------ --------- Length of each line___PA0_ ---------- ----- Total Length _9�0------------------ <br /> 'D''Box/l/,O- Type Filter Material /�&&,,26epth Filter Material ------------------- ---------- <br /> Distance to nearest: Well -------- Foundation -------- Property Line __8>42f____-_-_ <br /> --------- <br /> SEEPAGE PIT Depth _92,47 3%Y------ Number ed Yes g No C1 <br /> ---- Diameter --- ---------- ------- Rock Fill <br /> /- 0-i le-01, <br /> Water Table Depth ----45��---------------------------------Rock Size - ---------------- <br /> Distance to nearest: Well --- --'?-S------------------ Foundation -------- Prop. Line --- ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ------------------------------------ Date -----------------------------------) <br /> Septic Tank (Specify Requirements) -- ------------------------------------------------------------------------------------------------------------- ------------------------­- <br /> Disposal Field (Specify Requirements) ------------------------------------ <br /> ----------------------------------------:--------------------------------------------------------- <br /> ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------- <br /> -------- ---- -- --- - - - ------------- -- -- <br /> Draw existing a n d required addition o n reverse s i d e <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. Horne owner or licen- <br /> sed agents signature certifies the following: <br /> 1,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 subject to Workman's Compensation laws of California." it <br /> A <br /> Signed ---------------------- ------- - - ------------------------------------ Owner <br /> By ---- -- _o--------------------------------- Title -------- ------------------------------------------ <br /> (if than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- �----------------------- <br /> ------------------------------------- -------- DATE <br /> - <br /> BUILDING PERMIT ISSUE - - - ---- --------------------------------- -----DATE <br /> ADDITIONAL COMMENTS ---- ------- -- - -------------------------------------- ----------------------------------------*-I-�------P------------------------------------------ <br /> - <br /> - <br /> ----- -------------------------­--------------------------------------------- - - -- -- - --_-__V-------------- - - --------------------------- - ------------------------------------ <br /> -------------------------------I <br /> -------------------------------------------------------------------------------------------------- <br /> - <br /> ----- - <br /> -- -__ --_---------_ _------- _L___-----_ ___--___---------------------------------------------- <br /> --- <br /> ----------------------------- ---- <br /> -------------------------------------------------------------- <br /> Final Inspection by, -- _---.Date --9 <br /> q J0AQUIN10CAL HEALTH <br /> F. H. 9 1-'68 Rev. 5M. <br />