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FOOFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �2- �g <br /> {�orn�late in Triplicate) Permit No. ..... <br /> _Z____S_ 7 <br /> ---- ------- ------- This Permit Expires 1 Year From Date Issued Date Issued _�"_Z_�__7 7� <br /> Application is hereby made to the San Joaquin Local Health Districtr a <br /> described. This application is made in compliance with County Or. ante Nom549 and ex stingnRulestandtRegulatonsrein <br /> JOB ADDRESS/LOCATION .__.__-_- 49 3 s_2 y, ^< CC L CENSUS TRACT <br /> --- ----- <br /> ------------------------------ - <br /> -------- <br /> ----------------------•-- <br /> ----------------- - <br /> -------------------------- <br /> -------------------------------Owner's Name / .-----�-�--'•--- - - ---- -------Phone ------- -- - <br /> Address 5/4/+tet mss' <br /> ------- ------ - -----•---- ------- - - ---- City - C/f-G__� <br /> Contractor's Name ------- ��& <br /> ----------------------------------------------- <br /> License # Phone <br /> Installation will serve: Residence ❑Apartment House,❑ ommerciai❑Trail urt <br /> Motel Other --------------------- <br /> -------------- ----- <br /> Number of living units________ ___ umber of bedrooms _____--____Ga age Gr' /�, <br /> _-___.___ Lot Size _7_�____�R�S <br /> ater Supply: Public System and name _________________________ <br /> --------•------ -------------- ---- --------------------------------------------------Private E]Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat E] Sandy Loam >� Clay-Loom ❑ <br /> Hardpan ❑ Adobe ❑ F I Material ------------ If yes, type --------------------------- .l <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) (-33NEW INSTALLATION: (No septic tank or seepage pit permittif public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT Y <br /> [ ] SEPTIC TANK X n ---- Liquid Depth -----__._y_----•- - <br /> Capacity ------- Type ---------------- -- Material---- -- No. Compartments __ .. <br /> Distance to nearest: Well ----------------- ------------------Foundation -------- Prop. Line _----------- <br /> LEACHING LINE No. of Lines _-___~�-______.____ Leng f each line._____��___ - h <br /> Total Length _ d <br /> 'D' Box . _ Type Filter Mated ------- Depth Filter Material <br /> :a <br /> Distance to nearest: Well ______________ _ ____ Foundation ___._ Property Line. _______ <br /> SEEPAGE PIT [ ] wDepth =------_`-- Diameter ------ - ---- Number ------------------ -- ---- Rock Filled Yes [I No C]_W_ater-Table._Depth._- _ ----------s. . 4,k.- �, <br /> - - ,--------RocSize ----- --'--�--------------------- ;: <br /> Distance to nearest: Wel! _-____ --__ ____-Foundation ___-_.__ Prop. Line ____________________ <br /> PAIR ADDITION(Prev. Sanitation Permit# ------- ate <br /> Septic Tank (Specify Requir ment ) <br /> -------------------------------------------------- <br /> Disposal Field {Specify Req r ] <br /> �- <br /> .-F . _______ 4­ <br /> rqv - - -- ------------- <br /> nd requ' iti�rQin e) �1 hereby certify that I havep�e are tl ii s`efp icn anRa}'the oi . ne i act r once 1w' <br /> County Ordinances, State Laws, and Rules and Regulations of the'San Joaquin Local Health District. Home owner or lcen- <br /> sed agents signature certifies the following: y <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 <br /> s t man r sensation laws of California." <br /> Signed ------ Owner <br /> ------------------------------ <br /> BY - --- - - -- - -- ---------- Title <br /> (If other than owner) --------------------------- ----------------- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -__ o <br /> - ---------- ------------- DATE a --7 - <br /> BUILDING PERMIT ISSUED --------------- <br /> ADDITIONAL COMMENTS <br /> - ------- ------ --------------------------------------------DATE <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------I------ <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Final Inspection by: _____________________-_ <br /> ------- - - ---- --------f------ ------------------------------Date ------ ----- - <br /> ---------------------------- <br /> SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> r i <br /> E. H. 9 1-'68 Rev. 5M <br />