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FOR OFFICIE'USE <br /> < - APPLICATION FOR SANITATION PE T <br /> (Complete in Triplicate) Permit No. <br /> -------- <br /> 17/_ — -------- This Permit Expires I Year From Date Issued Date Issued __�J_= <br /> -- - f ' <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .___ ._f �� -_._ -- fS_ _ <br /> - -`- -- - -- -- - -- CENSUS TRACT ------------------------- <br /> Owner's Name "� <br /> !y - --- -- -- $1_t_.c-�.pc��---� G?1'�r�---------------------------(---�- ------- -- --Phone ----- ------------------------------ <br /> Address ,l��-- 1 - �' ,� ------------ . Cit- <br /> Contractor's <br /> it <br /> Contractor's Name -.-C' G, r------------ V----------------License # , 7� � Phone 4 _'�- "�_�l <br /> Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ---------------------------- -------------- <br /> Number of living units:---/__.- Number of be rooms _�Z------Garbage Grindere4l"OU_. Lot Size -'_�aP--__._ <br /> ,Q <br /> Water Supply: Public System and name _____ _ ._ --------------------------------------•---------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam D <br /> Hardpan ❑ Adobe J' Fill Material ------------ 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 SEPTIC TANK f;�' Size---% q p \ <br /> Capacity 4_GG-------- Type a MaterialNo. Compartments -------f_ <br /> r r <br /> Distance to nearest: Well .____.�Ov_____--_---_Foundation ___/_ --___-_____ Prop. Line ..... -----_--__ C <br /> LEACHING LINE X No. of Lines ------02------------- Length of each line-------- _ -------- Total Length ._h ------- ------- <br /> 'D' Box ---f----- Type Filter Material __av_ fG'Depth Filter Material -----/1;0_�it <br /> Distance to nearest: Well __ CG- ._----._ Foundation ---l_Cf------------ Property Line -__- ----------- <br /> SEEPAGE PIT [ Depth _ _ti`_�___. Diameter Number -----.r -------------_---- Rock Filled Yes No <br /> Water Table Depth ----.__, ' <br /> - -------------- --------------Rock Size --- ------------------------- <br /> Distance to nearest: Well _ ____________________________Foundation ../ --- Prop. Line ---- <br /> _______---_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------_____------------------_---------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -----------------_ -------------------------------------------------------------------- -------------------• ----------------------•---- <br /> DisposalField (Specify Requirements) ----•-------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse 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 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." <br /> Signed ---------------------------------------------------------------------------- ------ --------- Owner <br /> BY - title - tJ!G-_t 't ----------- -------------- <br /> (If other than owner) <br /> MR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------- ----------------------------------. DATE --`�-- ------ -/-------- <br /> BUILDINGPERMIT ISSUED --------- ------------------------ --------•-- -----------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------•----•----•--------------•-------------•-- <br /> --------------------------------------------------------- - ----- --------------------------------------•-------------------------------•------- <br /> ------------------------------------- -------- ,� <br /> - ----------------------------------------------------- - -- ---- --- ----- --- <br /> ------------- <br /> Final Inspection by: -- - -.Date _--- <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />