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. FOR OFFICE USE: <br /> Y' APPLICATION FOR,wSANITATION PERMIT <br /> f <br /> (Complete in-Triplicate) <br /> Permit No: <br /> ---Ap ----------------------- This Permit Expires i Year From Date Issued Date Issued -- =- ----------- <br /> Application <br /> plication 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 /> Gp <br /> JOB ADDRESS/LOCATION �_!__� --- --- L�-N _ ---------- --------------- CENSUS TRACT ------------------ ------- <br /> Owner's Name - <br /> --- ------- C14--�-- - --- -------------- ----------- =----------------- -Phone <br /> f Address /� � ---- t'J ---------. City lzipaftl------------------------------------------------------ <br /> Contractor's Name ---.r � c Lam/ =��-rp---�"P------------------------------.License # ---------:-------------- Phone ------------------------------ <br /> Installation will serve: Residence g)Apartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑ Other ------------ ------------------------------ <br /> Number of living units:----/----- 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'N Silt C] Clay .❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe '❑ 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 TREATMENT [ ] SEPTIC TANK:[ ] Size-------------•-------------- ------------------ Liquid Depth -------------------------- <br /> Capacity --------- Type -------------------- aterial----- --------------- No. Compartments ----------------- <br /> Distance to nearest: Well ------------------- --------------- undation ------------------- -- Prop. Line -------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length each li e -------- - ------ Total Length :----------.--..........--..5 <br /> 'D' Box -- -- -- Type Filter Materi ------------ -------Depth Filter Material -_____--_------_-----:-------------........ <br /> Distance to nearest: Well --------- -------------- undation ------------------------ Property Line. ------------. ---......r <br /> SEEPAGE PIT Depth Dimet <br /> ----------.. Number ____________________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depfih Rock Size 1 <br /> Distance to nearest:We _-------------Foundation -------------------- Prop. Line ------_--.------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----_-----_-----------------...--) <br /> SepticTank (Specify Requirements) -------- -------------------------------- ------------------------------------------------------• --------------•---------------------------- <br /> Disposal Fi Id IS ecify Requirements) ----------------------------------------------------------- ------ <br /> / - <br /> �,�c�----- <br /> --------------------------------- --- ---- ----------- ------------------------------------------------------------------------------------------/------------.-----_-----_----------------------- `J) <br /> (Draw existing and required addition on reverse side) c, <br /> I hereby certify that I have prepared this application and 'that the work will be done in accordance with San Joaquin I <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 to Work n's Compensation laws of California." <br /> Signed . ---`-- Owner <br /> P <br /> --- --------------------------- <br /> By ---- --- --- -- -- --- - ---- --- ----- Title ----- ----------------- ------------------------------------ <br /> [If of er than owner) <br /> �— FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------�---1---iK- 0------------------------------------------------------------------------- DATE ----- <br /> BUILDING ERMIT ISSUED ----------- -------- - ------------------------------------------------------------------ --------------DATE ---------------------------- -------- <br /> r <br /> ADDITIONAL COMMENTS ---- ------ -- -------------------------------- --------------------------------------- <br /> ----- - - ------------------------------------------------------------------ <br /> ----- --------- ----- ---------------- -- ------ - -- -- - ---- L;1-1- <br /> -- <br /> -------- ----------------------------- - ------- ----- <br /> Final Ins ectionDate ZP - ----- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> E, H. 9 1-'68 Rev. 5M <br />