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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. -�o��_:_-��-•`��---. <br /> ----------------------------------------------- <br /> (Complete in Triplicate) A <br /> --------- --------------------------------------- <br /> _ This Permit Expires 1 Year From Date Issued Date IssuedO��--�/----• <br /> ------------------ - --------- ---- <br /> al <br /> ealth <br /> rict <br /> e work herein <br /> Application is hereby made to the <br /> an compliance lian ecwitih CounttytOdinarna permit <br /> and ex sting RulestalndhRegulat ns. <br /> described. This application is P <br /> TRACT ------- <br /> JOB ADDRESS/LOCATION .. _ `��' ' ` "" "" � r - <br /> Owner's Name -- fG &-a---- - <br /> ��T <br /> %iG l ----� Phone <br /> ��jj �f Q` - City ----- <br /> ------/(/_A-- ----:--a_1" <br /> Address ,f <br /> Contractor's Name -___- _ - "r �r---__-_--""__-___--"_.:_-------.License #� �-- �� _ Phone <br /> Installation will serve: Residence ❑Apartment House Commercial ❑Trailer�C9ourt ❑ <br /> Motel ❑ Other <br /> Number of living units:.--_,/_--- Number of bedrooms --e_------Garbage Grinder/4 �-- Lat Size <br /> -•-------•- <br /> ----- ------------------Private �' <br /> Water Supply: Public System an name _-.--___"----------------------------------------------------------------------------------------- <br /> --- <br /> ---------- ------- -- <br /> Character of soil to a depth of 3 feet: Sand Silt E] Gay .❑ .Peat ElSandy •❑ Clay Loam <br /> Hardpan F-1Adobe ❑ Fill Material ------------ If yes, type --------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, <br /> buildings, etc. must be placed on reverse side.) <br /> P P public sewer is available within 200 feet,) <br /> SEPTIC TANK ` ----- -- Liquid Depth -- �-----------.----- <br /> NEW INSTALLATION: (No septic tank or seepage pit ermitte i <br /> PACKAGE TREATMENT [ ] Size/-_ - ' <br /> Type tom-f �+2- Material-�,� < - Na. Compartments -._`�^-----•--•---- <br /> Capacity, � ,� yp v <br /> Distance to nearest: Well _" _.I- --_----------------Foundation -ifs------ Prop. Line - ----•---•--- <br /> LEACHING LINE i ,No. of Lines ---r�--------------- Length of each line.__,4U-- --------- =---- Total Length .-/10'.2 .......... <br /> LEACHING <br /> Box - Type Filter Mat _;Z; Depth Filter Material Ze----------••---------- ------- <br /> �. - rte. , <br /> � . <br /> _. <br /> Fc-cdatiori a2 -- --- Property Line <br /> ,- Distance X-1 <br /> nearest:"Well _ -•a----"--- - � <br /> Depth -------- --------- Diameter -------- ----- Number ---- ------------------ -- Rock Filled Yes (] No .0 <br /> � <br /> SEEPAGE PIT [ ] P F <br /> Water. Table Depth ----------------------- <br /> Distance to nearest- Well ---------------- <br /> --------------- -------Rock Size ------------------------ ------ <br /> Foundation -------------------- Prop. Line -------------•----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- Date ----------------- } I <br /> I <br /> }i <br /> Sept ---- - <br /> ic Tank (Specify Requirement sl ------------------------------------- <br /> Disposal Field (Specify Requirements) -------------------------------- <br /> t ------------- <br /> I -------------------------------------------------------------- <br /> -------------------------------------- ------ ------ - <br /> {Draw existing and required addition on reverse si <br /> I'I I hereby certify that I have prepared this,application and that-the work will be done in accordance with San Joaquin <br /> 4 County Ordinances, State Laws, a` er or licen- <br /> nd Rules and Regulations of the San Joaquin Local Health District. Home own <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner <br /> as to become subject to Workman'sCompensation laws of California." <br /> C Owner <br /> Signed -- --------- ---prthan <br /> ---- --------- - ---- <br /> --------------------- <br /> Z - ------------------------ <br /> Title --------- l------- - <br /> i3y i {If owner) <br /> FOR EPARTMENT USE ONLY <br /> f APPLICATION ACC EPTED BYrr --1.�----`---------------------- ------•------ ----------------------------- - <br /> DATE - -G-_�---•---------•--------- <br /> BUILDING PERMIT ISSUED -------------- DATE <br /> ! ADDITIONAL COMMENTS ---------------------------- --------------------------- <br /> j --------------------------------------------------- ------------------------------ <br /> ----------- ---------- ----------------------------- ---------------------------------------------- <br /> --- <br /> --- ------- <br /> --------------------------------------------------------------------------------------------------------------------- -- Date ----�- ------ ----------------------- <br /> Final Inspection by: -------------- - ---------------------------------------------------------- <br /> F . SAN JOAQUIN LOCA HE H DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />