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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> {� ----------------- Permit No. .-- -5 <br /> (Complete in Triplicate] """"""""""" <br /> ------ ----------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date issued 7 <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.pnd Regulations: <br /> JOB ADDRESS/LOCATIONpq___ _��I1. _ _ ___ '�---_-C_l_+�f.�^�36y _---CENSUS TRACT -------------------------- <br /> Owner's <br /> ________ __ __ _ _Owner's Nome __ iZ l F -----(1-lo-,eevi --=- ----- ------Phone <br /> Address ----9--9,T ! City .F"! <br /> J -- ,� -�----- p� -- <br /> Contractor's Name ---- - '-----C�9l��il/ --------------------------------------License # - �✓__ - Phone _Qf 3_`7 '_ <br /> Installation will serve: Residence 5g Apartment House ❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- ! <br /> Number of living units:-----J!.... 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'[K Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ if yes, type ____________________________ a , <br /> N <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 14 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availabl within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] Size----------------- ____________________.____ ___ Liquid Depth -------------------- 1`4 <br /> Capacity - ------------- ---- Type ------------------ Mater' I--------------------- o. Compartments ---------------------- <br /> Distance to nearest: Well ___________________________ _______Foundation ------------------- Prop. Line ______________________ <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of a line_--------------- ----------- Total Length ___________.___.-__--_.._.__ <br /> 'D' Box ------------ Type Filter Material ---- -------------'_Depth liter Material ----------------------------- ........ <br /> Distance to nearest: Well ------------------- ---- Foundation _____________________ Property Line -_-_---.-____-___....___ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ------ --------- Number --------------------------- Rock Filled Yes ❑ No .c <br /> Water Table Depth -------------------- ------------------------ ock Size -------------------------------- <br /> Distance to nearest: Well ____ ____ ____________________ ____ ____Foundation -------------------- Prop. Line __________________--_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -_-___ _ _______ _____________ _ ___ _ ate ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------ --I--------- ---------------------------------------------------------------,..--------------- ----------- <br /> Disposal Feld (Specify Requirements) __________ __ <br /> /CY / -- - � ________------- <br /> 41 <br /> N _-__---_ <br /> /�W/- ---1MY 19 � / ---- <br /> ---------------- a <br /> --- ---------------------------- -------------------------------------------------------------------'----------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) ; <br /> 1 hereby certify that I have prepared this application and 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. Home owner or licen- <br /> sed agents signature certifies the following: r <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 War an's Compensation laws of California." j <br /> Signed ---- - ------ --- -- Owner <br /> BY = - �1----------- `-------------------------- T416 -- --------------------------------------------- -------------------- <br /> (If other than owner) <br /> R EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- --- --- ------- ------ - -------------------- ------------------------------------ DATE ...:d` y'� ------------ <br /> - -- - <br /> BUILDINGPERMIT ISSUED --------- - - ------------------------- -----------------------------------------------------------------DATE <br /> -------------------------------- --------- <br /> ADDITIONAL COMMENTS - - <br /> ----------------- ---------------------------------------------------------------------------------------I---------------------------------------------------- -------------------------------------- <br /> -------------------------------------------------- <br /> - -- - - ------ - <br /> Final Inspection by: --------------- <br /> ----------------------------- - Date J` �j <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />