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FOR 9FFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - --- --- - -- --- - - <br /> - Permit No. <br /> - -------------- <br /> (Complete in Triplicate) <br /> - <br /> -------------- <br /> - Date Issued ��'� <br /> This Permit Expires 1 Year From Date Issued <br /> " y)Y <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 /> --------------CENSUS TRACT -------------- ----------- <br /> JOB ADDRESS/LOCATIO ----1 �- -------- -------------�- - ----------- <br /> Owner's Name - 1 -------Phone <br /> ----------- ---- -------- ----------- <br /> Address +�.�� City ----- ------------------------------------ ------ <br /> ----/ , <br /> ------------- <br /> Contractor's Name ----------- ----- , -SOwr------------=--------License #�C7Vrrl�---.-- Phone y6�� ��7--- <br /> Installation will serve: Residence (Apartment House❑ Commercial DTrailer Court ❑ . <br /> Motel ❑ Other ---------------------------------------•---- <br /> t <br /> Number of living units:--- Number of bedrooms ---3-----Garbage Grinder ------------ Lot Size ------_--------------------------------_-- <br /> Water Supply: Public System and name ---------------------------•----•--------------------------------------•-------------- ------------------------PrivateX <br /> k � 7 fir,.::, <br /> Character of,soil to a depth " -,feet: Sand'❑m Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam[] <br /> . _ —_�._ L-- - -._.•_- <br /> Hardpan ❑ Adobe' Fill Material -""--------- If yes,type -------------"_------------- <br /> [Plot plan, showing size of lot, location of system in relation to wells, I3u Pdiiigs" tc. must be placed on reverse side.) <br /> 1 ,-� <br /> NEW INSTALLATION: (No septic tank or seepage-pit permitted i� public sewek'islavailable within 2d0 feet,) <br /> PACKAGE TREATMENT [ ] SEPTICTANK�[-]. v' " ==- Size_= -- -_------ --------------- Liquid' Depth ---------------------- <br /> ' syCapocitY ---------------- -- Type --------------- ---- Material------- - ------- No.i Compartments ----------------- <br /> l4 <br /> -Distance to nearest: Well -----------=--- u <br /> � ---�---,- -•r-�Fonda#ion ---- --------------- Prop. Line ---------------------- <br /> LEACHING <br /> ---- ----------------LEACHING LINE [ ] No. of L'in`es------------------------- Length of each ane�A ------------------ Total Length :-----.--------••----------- <br /> . -- ` __---"j;r._•_�_,_______---------------------- <br /> A -: Box] ------ - TypeFilter;Material --f------ ---{-De th�Filter Material <br /> i]istance to nearest: Well -------------- -------- Foundation -:-:--------------"---- PropertyLined______-•-.-.----------- <br /> i SEEPAGE PIT [ ] Depth-------------------- Diameter --------_�-_ Number ------ --------- hock Filled Yes [] No 1❑ ' <br /> 1Rock Size ------------------------------- 9 <br /> � Water Table Depth ------- ---------------------------------- - <br /> i Distance to nearest: 1Ne11 ---------------------------`-----------Fou-idhation -------------------- Prop. Line -----...--------____-- <br /> F � <br /> -----._.�'------'`� ------ ---------i <br /> REPAiR/ADDITIQN[Prey. Sanitation Perm it# -------- --- ---- Date ""--______-._____ <br /> Sepfic Tank (Specify Requirements) ; - -------- <br /> r� 4� <br /> F Disposal field (Specify Requirreeme�ts) -------- ''1 -•--------! Q------- j�Gnu '� U <br /> F <� a2 Gra'i-�.a --------f lrX <br /> -----------------------------`------------------- <br /> ' ----------- <br /> _ f <br /> '�j e --------------------------------------------------- <br /> I- ------tip`.-,- -I----- -'"1� <br /> (Draw existing and required addition on reverse side[ <br /> I hereby certify that'I.whave prepared this application and that the work will be done in Yaccordance with San Joaquin. <br /> County Ordinances; State Laws, and Rules and Regulations of the San Joaquin Local Health District. home owner or liicen- <br /> sed agents signature certifies the following: t <br /> that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject'to Workman's Compensation laws of California." <br /> ' Signed F = ---------------------- Owner <br /> i <br /> By : 4-- f Title -- ------------- ----- ---------------------- <br /> (If other' t wned ) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ----------------- ------ --------- <br /> DATE ".�'{�7 <br /> BUILDING PERMIT ISSUED .-.:W-- ---------------------- ,` <br /> - DAJE - <br /> ADDITIONAL COMMENTS �`"° �'``'�3 { ` . <br /> �s y = - -- <br /> " ------------------- ---------------�--- - 3v------------- ---- - <br /> { ----------------------------------------- - #-------2----�"`----------------------------------------------------------------------- <br /> ----------- <br /> FinallnspectionbYPE Date V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M _ <br />