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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .7�'_s°�- <br /> �I-----•----- <br /> ----- ------- ------ Complete in Triplicate) <br /> l Date issued . a7�---• <br /> -------------------------- <br /> This Permit E xp ices 1 Year From Date Issue <br /> -- <br /> � <br /> h ; the 4 <br /> k Application is hereby made <br /> adean Local <br /> with County Ordinance permit <br /> and existing Rulestall the work herein <br /> nd Regulations: <br /> described. This application <br /> .._CENSUS TRACT <br /> JOB ADDREISS/LOCA? e G ---------.Phone ------------- --------- <br /> Name Owner's ICitys ------------------------ <br /> ------- -- --- -- - - <br /> ------------ <br /> Address i, , t= <br /> License t�� e ®_ Phone ------ ------------- <br /> IF __! # <br /> Contractor s,Name ------ -- ---- <br /> ._-_- -- <br /> Installation will serve: Residence ❑Apartment Ho ❑ Commercial ❑Trailer Court ,❑ <br /> Motel ❑Other _ ---- <br /> ' Number of ',living units:_.--___.-_ Number of bedrooms- ----Garbage Grinder Lot Size -. = '- <br /> ip ------------Private <br /> Water Supply: Public System andname ___----------------------- <br /> --- ---------- - <br /> �i peat❑ Sandy Loam Clay Loam ❑ <br /> { Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ <br /> I� Hardpan ❑ Adobe ❑ 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.) L <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> � PACKAGE TREATMENT { <br /> SEPTIC TANK![ I Size_- -------------------------------------------- Liquid <br /> - �--- <br /> -- Depth ---------------- ---------- <br /> Capacity <br /> -------- <br /> Ca acctY -- - -------- - Type ------------ "�--- <br /> .� <br /> Material----- '-------------- No. Compartments --------------- ------ <br /> -------------------- Prop. Line ----------------• <br /> Distance to nearest: Well ----- - - --------------------------Foundation <br /> K, ! Total Length <br /> LEACHING,LINE ( ] No. of Lines Length of each line________------------ <br /> ------------- <br /> De-Depth Filter Material -------------------------------------------- <br /> k Q 'D' BoxI------------ Type Filter Material --------- ------ -- : p <br /> r i! Foundation -"" -- Property Line ---------------- <br /> Distance to nearest: Well ______________________ � ------------------- <br /> Yes <br /> - �- <br /> !� ) Rock Filled Yes ❑ No i❑ <br /> SEEPAGE PIT [ j Depth _ Diameter --------------_ Number?---------`------- <br /> ------------------- <br /> i I! Water Table Depth -. -------------7------ ---Rock Size <br /> i <br /> II l Foundation Prop. Line ------------ - ------- <br /> Distance to nearest. Well y--' t <br /> t� <br /> - ------ ----=Date ---------------------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit - ---•- <br /> - <br /> ------ <br /> --------------- -- - <br /> Septic Tank (Specify Requirements) _---._ _ ----- <br /> ,"Disposal Fie d {Specify/Requirements) --T-- <br /> 1 __lip Q ________________________________ _________________________ <br /> "--"_"____---.__"__"_--.""___"___________________________________"-"_-___.-.__-_ <br /> 3 , <br /> - ---------------------------------- <br /> =--------- ---------------r--------------------------------=------------ <br /> i (Draw existing and required addition on reverse side) <br /> 1 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 Rulesand Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed`agents signature certifies the following;., arson in such manner <br /> "I certify that in the performance of the work-for which this permit is issued, I shall not employ any p <br /> as to become subject to Workma ompensation laws of California." <br /> Il --- -Owner <br /> ' Signed... �---=� -, . ._::.--�- - - '- -- - _ - -- - -?� - <br /> - Ca <br /> ` <br /> I! Title <br /> -. - - - ------ -- --- ----- -- ------- -------- <br /> BY -----------------------(if other than owner) _ -(- �` ` , :,. . ,I + 4, <br /> FOR�DEPARTMIE USE ONLY <br /> APPLICATION ACCEPTED BY -" -- ------------- -------------------------------------------- <br /> : ---------------- <br /> --- DATE _-_6._ 1'.7- ------ ------------------- <br /> BUILDING PERMIT ISSUED -- --------------------------------------------------------------------------" -"------------------ -- <br /> ----------- <br /> --- ------DATE -------- --------------------------------- <br /> BUILDING <br /> -------- ------- -------•---- <br /> ADDITIONAL COMMENTS -----------•---------------------------------------------------- - --------- <br /> - ------------------------------------------------------------ <br /> I ---------------------------- - <br /> - --------- ------------•------------------------------------------- - _ <br /> ------------------------------ <br /> Fina{ Ins I / -- -- <br /> ----------- -- <br /> � i� _ ------- -----.Date -- ------- --------- <br /> ----------ection b <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M. <br /> .F <br />