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h b <br /> FOR OFFICE USP.;, <br /> o �R APPLICATION FOR SANITATION PERMIT <br /> Permit No. ---- <br /> �� �d (Complete in Triplicate) <br /> '"----- �— <br /> -------- ---- -------------------------------- Date Issued --- � <br /> -- --[--- <br /> This Permit Expires 1 Year From Date Issued <br /> Application hereby d 'ie <br /> o the acomplianceJoaquin County District install <br /> herein <br /> described. Thispplaonismade in wih Ordinana No. 549 and existing Rules and Regulations. <br /> I <br /> JOB ADDRESSJLOCATIOIV'i._-_--- --� -�'?-- -.-- --- - --� ---- --- - --- --- <br /> -----------CENSUS TRACT -------------------------- <br /> �' ----- ---- ---- ----- -------- ---Phone <br /> Owner's Name ------------------------ �,�:�-��__�---•--------•---- ------ - <br /> Cifi y" G -------------- <br /> Address - --------- - - _l----- `--- -- =--I-- eX Y } <br /> r Name Q License #/- �E j- Phone <br /> Contractor's me 0---..__1Ca '� ------ -----------------•------ <br /> Installation will serve: 'I Residence rtment House ED Commercial ❑Trailer Court ,❑ <br /> k � Motel E]other - ------- ----- ---- --------- ----- ---- <br /> ,_ ---Garb e Grinder!1L�---- Lot Size ��..���--------------- <br /> Number of livingunits:---'--/---- Number of bed oms .. <br /> �l <br /> I (_SLC-�+ Yv(� ---------------•----•----.__Private ❑ <br /> Water Supply: Public System and name ------------ ----- 1_,-.... -.- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loom ;❑ <br /> E <br /> Hardpan ❑ <br /> Adobe Fill Material __.1_V__.__ 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,) \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ I Size------------------------------------------------ Liquid Depth <br /> No. Compartments -------------------•-- <br /> Ca acifi ----- Type -------------------- Material.------------------- <br /> p <br /> Distance to nearest:.Well --------------------------•---------Foundation ---------------------- Prop. Line- ---------------.------ <br /> IETotal Length LEACHING LINE { ] No. of Lines ----------------------- Length of each line-------------------_---- 9 _.--------- <br /> D' Box ------------ Type Filter Material -- -----------------Depth Filter Material --------------------•----------- <br /> 1 - - Pro Property -------•-----•- <br /> Distance to nearest: Well -..---- -.--_ Foundation --------------------- <br /> SEEPAGE PIT [ ] Depth Diameter --------------- Number --------------------------- Rock Filled <br /> Yes ❑ No ❑ <br /> -------------- ----- <br /> Water Table Depth --------------------------------- Rock Size --------------- <br /> Distance to nearest: Well -------------------- <br /> -------------------- ------------------- Prop. Line <br /> REPAIR/ADDITION(Prev.,Sanitation Permit# -------•---•------ ------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---- ---------------- <br /> ------------ ------------------ - <br /> Disposal Field (Specify Requirements) - `'' A,� <br /> - ------------- <br /> L� /`- ------ --------------- <br /> ------ <br /> ------ ----- -=- ----- _' --- <br /> -- --- <br /> - - ----------- <br /> -------------------------------------- - - <br /> `` (Dra xisti andxequ' addition on reverse sEde) <br /> I hereby certify that I have prepared is application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the.Sari Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: `.` <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 subject to Workman's Compensation laws of California., <br /> Owner <br /> Signed Lt.�I - <br /> --------------------------- --- <br /> - Title - ------------ ------------- ------- <br /> (If at,er th' ed <br /> II ;FOR DEPARTMENT USE ONLY <br /> ------------- --------------- DATE ---74ir -----------f ¢ <br /> APPLICATION ACCEPTED BY _rec L- y a 'fid DATE <br /> BUILDINGPERMIT ISSUED ------------------------------- -- - ----------------� ------- -------------------------------- <br /> ADDITIONAL COMMENTS ---------�,__.J­6- -_____ __________________________________________ __'___ -- ------- -- -1 ----_--____--____--____--____ ::__ --____ ___ --____ ____---____-___-_::____._______________::____-_ <br /> = -- . t� 6 <br /> ---------- : Date - <br /> ----------- <br /> ----------------------- - <br /> ----------------------------------------------------- - <br /> Final Inspection b } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i! <br /> E. H. 9 1-'68 Rev. 5M <br />