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AOR (?Plf ICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate} <br /> Permit No' D ___ <br /> _______________------------ ------------------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 �J� ------- �.......���-------- -- ---- ---------CENSUS TRACT -------------- ----------- <br /> Owner's Name - -� -�/ z• ----�Cr!�.��.���� --------- --�/•�-------------------Phone ---------------------------•-------- <br /> Address -- =-------------------------------- ------------------------------------------------• City sc9' ----------------------------------------------- <br /> Contractor44 Name,�� '__S, T t J,tl_C------------------ #f;�7j 3.-_ Phone 4_'/_ <br /> Installation will serve. Residence ®.Apartment House❑ Commercial :❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__'----. Number of bedrooms ______Garbage Grinder _X'�'__ Lot Size C?___s i -! <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private, <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 1] <br /> Hardpan ❑ Adobe-E] Fill Material ---- --- 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 TREATMENTSEPTIC TANK' Size- - <br /> { ] � ��.�r--.�4����- -- --- --------- Liquid Depth --//--------------------- <br /> Capacityxzl7ve�­ /` Type/ _ Materials-� 4� ___ No. Compartments 4............:.... `.'V <br /> Distance to nearest: Well ------------------------------------Foundation -..---- -------------- Prop. Line ------------------------ <br /> ' <br /> LEACHING LINE kJ No. of Lines ..../----------------- Length of each line-----b r ______ Total Length _7_0--- <br /> -___--_-----._--_ i <br /> 'D' Box 4/C7----- Type Filter Material _1PoCJ0t---Depth Filter Material ---/_- _________________________________ <br /> Distance to nearest: Well .___ `{ ___'_."Foundation =, ?``.".._.__ PropertV-Line :f'_ _______________.. " J <br /> SEEPAGE PIT [ Depth ------ --- Diameter Number ----------�--------------- Rock Filled Yes P---N-0 .0 <br /> Water Table Depth ------ -7 ----------------------------Rock Size ------------------------------ <br /> Distance to nearest: Well ------------------------------------------Foundation -------------------- Prop. Line -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# sX_26i 1_;7----------------------- Date _-_---j <br /> 1 <br /> Septic Tank (Specify Requirements) ----- ----------------------------------------------------------------------- --------•--------•----------------------------- ' <br /> J <br /> Disposal Field (Specify Requirements) ------ -------------------------------------------------------------------------------------------------------------- ----------- <br /> v <br /> t r <br /> ' ------------------------------------------------------------------------ <br /> - - (Draw existing and required addition on reverse side) <br /> I 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: <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 o Workman's Compensation laws-of California. i <br /> Signed .�sZLLLOwner <br /> - --------- <br /> By ---------- -------------------------------------------------------------------------- <br /> j <br /> - - Title ------------------- ---------------------------------------------------- <br /> llf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ;, i <br /> APPLICATION 'ACCEPTED BY --- -� 6 ---- --- -------------------- DATE - -----7 .1lr -------- <br /> BUILDING PERMIT ISSUED -----------------`----------------------------••---•------ • DATE <br /> ADDITIONALCOMMENTS ----------- ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------- <br /> ------------------- ------------------------------------------- -- ------------------------------ -- ------- --------------------------- ---------- -------_----_------- .............. <br /> ------------ <br /> ------------------------------------------------------------------- _ <br /> Final Inspection by: ------------ -!- �" Date /" ------ -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> E. H. 9 1-'68 Rev. 5M <br />