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FOR OFFICE USI:: i <br /> APPLICATION FOR SANITATION PERMIT g <br /> ...................................................... (Complete In Triplicate) Permit N4X- ...:9 !. <br /> ..................I...................................... This Permit Expires 1 Year From Date Issued Date issued to '.T�� <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,mad t (lance Co Ordinance Na. 549 and existing Rules and Regulations: <br /> 1 �Iva I4 .. 1�?e.: CENsuS TRACTJOB ADDRESS LOCATION .krl. . .�.'��.�?4�.t�.. .... . .... ............ <br /> Owner's Name ... L? .H3. S.1 ..C� :.f .i i[�3 .....................Phone ........... <br /> Address ... .� �?:. !L4wxA,_6�� v.�L.City <br /> .... .... <br /> Contractor's Name % .. Phone <br /> Contractor's <br /> ..-•-- f P,&W.4..............•--.............................................:License <br /> Installation will servev 1°Residence E]Apartment House❑ Commercial❑trailer Court ❑ <br /> Motel.64•0ther.... FR--- 1. 1"l.C'....... <br /> Number of living units:_.?.Q... Number of bedrooms ..<?..Garbage Grinder ............ Lot Size .. ms.......................... <br /> Water Supply: Public System and name ..................................M.._........................_..........................................frrivpts z <br /> Character of soil to_ a depth of 3 feet: Sand❑ `Silt[] Clay ❑ Peat❑ Sandy Loom ❑ day Loam ❑ r <br /> Hardpan❑ Adobe ill Material ............If yes,type............... ............ <br /> A <br /> Mot 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 /> r PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size................................................ Liquid Depth ........................ <br /> ECapacity ............••...... Type ................... Material...................... No. Compartments ................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line .................... <br /> LEACHING LINE [ ] No. of Lines ......................... Length of each line............................. Total Length .......................... <br /> `D',Box ............ Type'Filter Material .:.................Depth Filter Material ._.......................................... <br /> . , Distance to nearest: Well .::` ............... Foundation ........................ Property Line ................ <br /> SEEPAGE AIT [ ) Depth .................... Diameter ................ Number ......................:..:. !tock Filled Yes ❑ No <br /> Water Table Depth ............... ! .............................Rock Size ..... .::.............. <br /> Distance to nearest: Well .........................................Foundation ................... Prop. Line ................ <br /> REPAIR/ADDITION[Prov. Sanitation.Permit#' -•- . ....:. . ........... Date ...... _ --------• -] <br /> Septic Tank (Specify Requirements) ...... U►i.Nk:.............................................................................................._................. <br /> t Disposal Field ISpecify Requirements! .. , <br /> ........... CJ....n ?t, ?_..... L .............................. ............................................................................................................ <br /> �. .....--•.. ............................................ Draw existing and required addition an reverse side)., ...................................................... <br /> I hereby certify that 1 have prepared this application and,that the work will be done In accordance with San Joaquia <br /> County Ordinances, State.Laws, and Rules and Regulallons of the San Joaquin Local Health District. Hants owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this peimit is Issued, I shall not employ any person in such monitor <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ........ .............. ......... .. ......... ............................ <br /> .........:.....:..: Owner <br /> sy ......... `-. ... ? �...G .......... .......... . ... ....... pile .. `:....................................... ............ <br /> [!f t r than owner) <br /> k. FOR DEP TMEN USE ONLY , <br /> APPLICATION ACCEPTED 6Y................................ ..•.... .: . :.. .. Xi............. DATE .......... ���.........---------- <br /> BUiLDING PERMIT ISSUED ..............:......:... ........DATE <br /> ADDITIONAL COMMENTS l_.... .-... ........:..............•------------ <br /> ....................------........----......-..... <br /> .. <br /> ........................ .................. <br /> #fi <br /> ................................_....-.-................................---.................--......--........................... -.............. ................... <br /> �r�.......Date ........... - -..•. ., <br /> final inspection by: •••••••••••-----•- <br /> Mi Z3 2 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH ISTRIGT 8 711 3H <br />