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FOR OFFICE USE, APPLICATION FOR SANITATION PERMR <br /> a.... - - <br /> 76 <br /> ..............:: ....................................... PermitNa. ....... <br /> . ....................................... . (Complete In Trlpilcote) Dab Issued :l:.-:.Y.9d.. <br /> ..7...0.. <br /> _.......... .............I.............................. This Permit Expires 1 Year From Date Issued <br /> Application Is hereby made to the San Joaquin local Health District for a permit to construct and Install the work hereii <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationst <br /> r... ....... Gl :.. ........_CENSUS TRACT,rx:.................:.... <br /> JOB ADORES3%L TION .--- -4 _ R <br /> Owner's Name .....--- .G'/f//�i&;t'..- Q. .�............................................................Phone ................................... <br /> Address ............................ �Q- �........................----.....................City ........................................................................ <br /> Contractor's Name ..................r:....V. ;GIt"Ament <br /> ....................................License # ..._.................... Phone ........................ <br /> �.instollation will server Residence House❑ Commercial❑Trailer Court ❑ <br /> ' Motel ❑Other <br /> Number of living units:.....I..... Number of bedrooms .. Garbage Grinder ............ Lot Size ......................................j... <br /> Water Supply: Public System and name ................................._.....................-........._......._................................Private <br /> Character of soil to a depth of 3 feet: Sand IJ Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loom ❑ <br /> Hardpan Adobe❑ Fill Mate►lol ............ 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 i ) Size................................................ Liquid Depth ........................ <br /> Capacity .................... Type .................... Material...................... No. Compartments ........_..... .... <br /> z Distance 'to nearesh Well <br /> ....................................Fou anon ...................... Prop. Line ................... <br /> TEACHING LINE [ } No. of lines .. Length of eachline............................ Total Length .......................... <br /> V Box ............ Type Filter Material ....................Depth Filter Material .......................................... <br /> Distance to nearesh Well ........................ Foundation ........................ Property Line ......... ... <br /> SEEPAGE PIT Depth .. Diameter ................ Number ............................ Rock Filled Yet 0 No <br /> WaterTable Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundati ...... . . ...— Prop. line ........._......... <br /> 1 . <br /> REPAIR/ADDITION(Prov. Sanitation Permit ...__ ., .................. Date .':� .. g�_......) <br /> Septic Tank (Spedfy Requirements) .............. .. . .......... --............. .......... .. ................ <br /> ... / ........ ............... <br /> Disposal Field (Specify Requirements) . . (,�.. .......7/ . <br /> .............................. ...........................................................-----------...............-----... . <br /> .................................................................................................._......................................................................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaqu <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hem* owner w lice <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 mann <br /> as to becorne subject to Workman's Compensation laws of California." <br /> .):gned ..........................................................................................X- Owner <br /> 8y .................. .......................... litle ......................................................................-- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..... .0 91... _. ....---..................................................... DATE ......0� ... ..7.. .......... <br /> BUILDING PERMIT ISSUED ........ ....... n �-y <br /> ADDITIONAL COMMENTS 7 �. ... <br /> !. -� �rLrd` ... .. .............................................. .....1 <br /> i. ................................... .................... .................................... ............ <br /> Final Inspection by: .. ... .. .......................................•.................. ......................................Date ...... ............. <br /> Ell 13 2L 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7ls 3M <br />