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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .tet. ,, Permit No. <br /> {Complete in TrOplicate _. <br /> ) �?- <br /> ------------------------------------------ -,•-4. �� I <br /> Date Issued _ _.-_/!®_"._7J' <br /> 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 herein <br /> described. This application is made'in compliance with�County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ��_���__ __. _ _ _ ----- ----� <br /> ------------------ -- -------- --- CENSUS TRACT ------ <br /> �.1 7 Phone <br /> _s _ <br /> Owner's Name _ _,ee -�''`', -------------------------------------------------------- ------ --- <br /> Address . - ------------------------------------ City <br /> Contractor's Name -- ---------------------------------------------•---------.License # _ __ Phone 1;567,T <br /> r <br /> Installation will serve: esidence ❑Apartment House-E] Commercial ❑Trailer Court ;❑ , <br /> } Motel ❑Other ---------------- <br /> Number of', <br /> f living--units:-_--:--Number of bedrooms - ___--Garbage Grinder ------------ Lot Size ----------------- <br /> 0. <br /> Water Supply-;Public System and name - - '��------- • ---------Private ❑ <br /> IE <br /> s _ <br /> Character�of soil to a depth of 3 feet: I Sand'[] Silt 0 Clay F-1Peat F-1SandyLoam Clay Loam ,D [ <br /> Hardpan ❑ Adobe_-❑ Fill Material _____-_____ If yes, type ___________________________ <br /> t > <br /> {Plot plan, showing size of. lot,-location of system in relation to wells, buildings, etc. mist be placed on reverse side.] <br /> NEW INSTALLATION:; {No septic tank r seepa pit.permitted-if public sewer is available within 200 feet <br /> Ljj U <br /> - <br /> 7,3 <br /> PACKAGE TREATMENT [ SEPTIC TANK' �..h .; .'Size--/;l?_.------ --- - Liquid Depth ___ _ ................... <br /> i. <br /> 6paLelty a __ Type - -1_ Material_ __ _ No. Compartments <br /> 1 I !� Foundation __ _' Pro Line __- <br /> t , Distance to nearest: We s i ,` �� P <br /> LEACHING LINE` ]i No—of Lines �_____ _ /- Length of each line. ________ _'� _ f l__ Total Len ©©- { <br /> �L C�13 --'-D'-BoxL �_��- Type Filter Material � C Depth Filter Material. --, ------------------•--------� i <br /> nn + <br /> 3 <br /> �`Qv Distance to nearest:,Well _-_ _L-------_--- Foundation _-__� ------------- Property Line _-_ ---:.--- <br /> SEEPAGE PITS [ DepthiDiameter -______________ Number . f I <br /> ___.__.___----------__---- Rock Filled Yes ❑ No ❑9� <br /> ` Water-fTable Depth ------------------------------------------------ <br /> Rock Size -------------------------------- <br /> C2 <br /> ------------------------------- <br /> 1 �' . cti <br /> -------------•-Foundation ----------_----_---- Prop. Line --••---•--•-------- <br /> j4l Distane to nearesWell --------------------- .CNI <br /> REPAIR/ADDITION(Prev. Sanitation. Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------ ----------------------------------------------------------------------------------- ----- ---------------------•-1� <br /> Disposal Field {Specif Requiirements) ----- 4--------- --------------------------------------------------- <br /> --------------- -------------------------- <br /> t ----------------=----------------- -------------------------- ----------------- <br /> ---- ------ ----- <br /> ----- 1---------------------------------: ------------------------------------------------ ®{ <br /> g <br /> [Draw,existin and'required addition on reverse side) <br /> I hereby certify,that I have prepared this application Will that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local: Health District. Horne owner or licen. <br /> sed agents signage certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shallnot employ any person in such manner <br /> i <br /> as to become subje5t to Work an's Compensation laws of California." , <br /> Signed (. ------------------------------------------------------- Owner i. <br /> _ ,Title ----- <br /> ---------------------------- ---------------------------- <br /> [If-othe'r,than: <br /> r = F','i1 1 V',I: FOR DEPARTMENT USE ONLY <br /> APP.LICA710N ACCEPTED BY. ±- `� : - ! DATE --- <br /> -------------- <br /> BUILDING PERMIT ISSUED ---------- - ---------------�°DA.T.E------------------------------ _------•-- <br /> ------------------ = <br /> ADDITIONALCOMMENTS _ _ --- -- -- - ----------------------- --------------------------------- ----•- ------------------------------ <br /> ............... .... �. ,, <br /> - - - --=- _ -------- <br /> ----- - , <br /> ------------------------------- ----------------------- ------ ----- -------------------------- <br /> ------------------ <br /> -----.------------- 1 <br /> ----------- ------ <br /> ' <br /> ------------------------- - -- -- - - - <br /> Final Inspec Date --- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />