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FOR OFFICE USE: <br /> 4 APPLICATION FOR -SANITATION PERMIT <br /> ---- ----------------------------- 9�%-------- Permit No. <br /> (Complete in'Triplicate) <br /> ------------- ---------------- <br /> 1� �- - Date Issued ._. <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 compIia e it _C�oun3y Ord' ane No. 549 and existing Rules and Regulations: <br /> S / C r , <br /> JOB ADDRESS LOCATIO' �_f4- �aG d?� - --------�1----. _ - `cNSUS TRACT -------------- <br /> / !�'� <br /> Owner's Name _ �k�'' /` <br /> --------------- ---Phone ------------ ----------------------- F <br /> Addressi Jk ------------- ------------- -• CitY <br /> ' ' <br /> PhoneLocense #v7Contractor's Nameeon ----------------------- <br /> Installation will serve: Residence ❑Apartment Holse,0 Commercial :[-]Trailer C 0' <br /> Motel ❑ Other ---- --------- ----------------------------- <br /> Number of living units:_______ Number of bedrooms _ -_Garbage Grinders __ Lot Size ---------------- <br /> Water <br /> ------------•--- <br /> Water Supply: Public System and name ------------- - ---------------- -------------------------------- ---------- ----- A-----------•-------------Private, <br /> V Character of soil to a depth of 3 feet: Sand❑ Silt Clay E-] Peat F-1Sandy Loam,❑ Clay Loam.0 <br /> Hardpan E] AdobeZ Fill Material ------------ If yes,type3_ ________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must bd p� 14 11laced on reverse side.) <br /> NEW?INSTALLATION: (No septic•tank or seepage pit permitted ifpublicsewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK Si 00 'f� /------------------ Liquid Depth .............. <br /> - <br /> Capacity/�/ �_____.__ Typ --- Material No. Compartments -�----- -------- { <br /> Distance'to nearest: Well ___--� �,�_______________Foundation ,/f ----_---_--- Prop. Line -4 .._______._ <br /> LEACHING LINr=. No. of Lines _____ _______________ Length of each line__/ezo______ -_ Total Length , � -•-..--------- <br /> 'D' Box _ Type}FiltertMateriral•//1, Depth Filter Material"�-�`_________________ ________________ <br /> Distance to nearest: Well _--/' - - '- Foundation <br /> _____.__- Property Line __ * fes'_ -____. <br /> SEEPAGE PITj Depth _+ _______ Diameter - '- Number ------f------------------ Rock Filled YEs,V' No C3 <br /> Water Table Depth ----------� ---------•--- ----- ------Rock Size = ---------------- <br /> e <br /> Distance to nearest: Well _____ - -------------�-----Foundation Prop. Line ---------------------- <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------.•.------------------------ ------ .= Date -------------------------------•--) <br /> Ir <br /> Septic Tank (Specify Requirements) --------------------------------------------------- ------------------------------------------------------ <br /> --------------------------------------------------- ------------- <br /> Disposal oField (Specify Requirements) ------------------------------------------- ------------------------------------------,-------------- <br /> ---- <br /> � ----------------------------------- <br /> _ _ -------------------- ------------------------------------------------------------------------------------------------------------------- ___.__-_________-_-_-___- <br /> N _(Draw existing and required addition on reverse side) <br /> I hereby certify hat I Have prepared this application and that the ``work will be done in accordance with Son Joaquin <br /> County Ordinances, State Lawsr and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- <br /> led agents signature certifies the following: <br /> "I certifythat'in=ttfe �rformance of the work far whichthis permit Jissued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.',' <br /> Signed ------------------- ---- - ------- - --------------------------------- Owner <br /> �7� <br /> 4 = '---------------------------- Title L u - <br /> (If of than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �---- -----------------------------(- --------------------- DATE f R 2 <br /> BUILDING PERMIT ISSUED '1t -------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS �-- r'- <br /> -------------------------------------------------------=--------------------------- <br /> E r <br /> ---------------------------------------------------=-------------------------------------------------- <br /> -------------`-------------------------------------------------------------- ---------------------•- <br /> -------------------------------------- <br /> z <br /> -- -- ------ - - <br /> --------------------- ----------------------�----------------- ---- ---- - - --------- /X/ <br /> --- -------=------- <br /> Final Inspection by. ---------------------Date ------ - / <br />> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � 5 i <br /> E. H. 9 1-'68 Rev. 5M a • `'� ' , , _ <br />