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FOR OFFICE USE: <br /> -_x/-_-,,- , VeSan <br /> APPLICATION FOR SANITATION PERMIT <br /> 4----------- ------ Permit No. _�.z-_�_6 <br /> r (Complete in Triplicate) <br /> -_--- This Permit Expires 1 Year From Date Issued Date Issued __�_�_�:---- <br /> Application is hereby made toJoaquin 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 ---.51._x:.- ------- �_fi � _� - Q--------_ -1----------- CENSUS TRACT --------------•----------- <br /> Owner's Name ----T-em---------R-------- _v _�+_� ------------------------------------------: -------- ---------Phone --- <br /> Address <br /> -Address ----------- 1rmd:- ------------------------- --------------------- ------------ City ----------S'T_o_ --1C7`Q N---------------------------------- <br /> Contractor's Name --_C Rrt. _t- ------- -----------1-H—C------License # ___ Phone - <br /> Installation will serve. Residence YApartment House Commercial ❑Trailer Court 0 <br /> Motel Other ------------------------------- ----- ---- <br /> Number of livingunits:___._ _ Number of bedrooms _ ----------Garbage Grinder ------------ Lot Size ------ -- ------- - ------- <br /> Water Supply:Public System and name ------------- -----------------------------------------------------------------------------------------------•Private ` <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) S <br /> PACKAGE TREATMENT [ ] SEPTIC TANK _ ------------------------ <br /> Size-______ ___�_1ar � <br /> Liquid Depfih --------- ----- <br /> 'Capacitylbw_ 1>�-_ TYpe1� _-C-1&!-Material___�P No. Compartments ____________________ <br /> Distance to nearest: We ll ---------� - <br /> - _ �' <br /> 'D------------=-------Foundation ----�0_--------_ Prop. Line ----..s�----------- -� <br /> LEACHING LINE `� No. of Lines. ........Z-tf_ Length of each` line______._KA___-__-<-___ Total Length ------1.7-0. ....... <br /> :__ <br /> ')'D; Box ----- Type Filter MaterialDepth Filter Material ------------LS__-- <br /> . Distance to nearest: Well' ------CQ___________ .Foundation '------$__Q------------ Property Line _____c ______________ <br /> SEEPAGE PIT I.,Depth, ____ ______ Diameter ___ ______ Number _______.��--- Rock Filled Yes " No i❑ <br /> e0lf <br /> Water Table Depth ____s -- -----------Rock Size -------2A-- ------------ <br /> 4Q_.______ Prop. Line _____+�-x <br /> Distance to nearest: Well '____ __�V_--______�______________Foundation _____ _ _ ---___--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit-#,.....' --------------------------------- Date ----------------------------------). � <br /> Septic Tank (Specify Requirements) �I --- <br /> DisposalField (Specify Requirements) -----------_-------------- ------------------------------------------------------------------------------------------ --------------- <br /> ----------------------------------;--------------------------------------------- ---------------- ----------------------------------------------------------------------------•------------------------ <br /> (Draw existing and required addition on reverse side) N i <br /> I hereby certify that I have prepared this application and that the work-willFin'accordance withf 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: I •'4s 1 <br /> "I certify that in the performance of the work for which this permit is issued, I shalV=n t employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.'.' :- <br /> Signed -- ---- ----------- --------f---------=-------_------------------------------------------- <br /> --- Owner l <br /> BY ------ Title ------------------------------- --' <br /> ------------------ -------------- <br /> (If other than owner <br /> FOR RTMENT USE ONLY, - " <br /> APPLICATION ACCEPTED BY DATE. 1 -------- <br /> BUILDING PERMIT ISSUED ---- - - <br /> = DATE ---I- <br /> --------------------- <br /> COMMENTS ---- -- --- -- - ----- ---------- w --------- --------------- ------ ------ = <br /> ---------------------------------- ------ - -- - - -- -- ------ ------ - -------- --------+_.:----- --�- ------------------------ ------------- ----------- ------------- <br /> -------- ----- <br /> ---- - i _ -- - ------ - -------------------- <br /> ---------------- - ----- ----- -----'--------- -- --- ------ - ----------------------- -----=------- <br /> -- - - - ----- -- --- <br /> Final Inspection b --- ------ ----- '--- ------ " ------� •------------ Date <br /> iSAN JOAQ IIN LO AL-�HEALTH DISTRICT <br /> r= <br /> E. H..9 1 '68 Rev. 5M ) t �- <br />