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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 0 <br /> __ {Complete in Triplicate) Permit No. - - ......... <br /> This Permit Expires 1 Year Front bate Issued Date Is ued`: :.�6. 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 Count_-6rdinon4e,.Nc` 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION � �. .... <br /> CENSUS TRACT ..---•-•--._............._ <br /> ------- <br /> Owner's Name ----------- -------------- <br /> ���•l-�r-��"-�-�-�.�----••- •- . <br /> ..-_.` :...-_.... one ................. <br /> 3 <br /> Address .........:. ...1�'�'I,f:-t�-:...._....----.....------ - ---•--- �-----_.. City :.��.��` /�.....-... . <br /> ........... <br /> Contractor's Namex . t_ e/ � ---- t <br /> ------ .._._-License #�. .���_ Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel 4 <br /> ❑Others,---------------------------- <br /> Number <br /> ---- - •------- ---- = --=-----------•- <br /> Number of living vnits:..../..... Number of bedrooms �_.__.Garbs e Grinder <br /> 4 �y g / l>... Lot Size .1.41V--- .l, @'.............. <br /> Water Supply: Public System and name ._..4..Q <br /> �T'1-.�/]-`� ° ��---••...................................••---,:Private ❑ .�^'� <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Ciay [I .Peat[3Sandy Loam E] Clay Loam F1 ' <br /> ! hardpan ❑ Adobe Fill Material Ifes, type YPe ...--- .......... l <br /> (Plot pian, s}iowing/size-of,lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I <br /> NEW INSTALLATION: /i'(No septic tank or seepage pit permitted if public sewer is available within <br /> ,200 feet,) <br /> PACKAGE TREATMENT .� —- <br /> -- - ._ - <br /> [ �.t SEPTIC TANK <br /> Size..._. Liquid Depth <br /> Ccipacity .. I <br /> Type - Material-.---.-.-.-- - ------ No. Compartments �nf <br /> ,Distance to nearest: Well --.....Foundation ...................... Prop. Line ...... <br /> LEACHING LINE No'of Lines .. .. --.. _ • length of each line Total Length <br /> i <br /> t r <br /> D' Box <--. Type Filter Material ....................Depth Filter Material -----------*------------ <br /> _..... _. ._......___ .. <br /> Distance`to nearest: Well ........................ Foundation _ <br /> Property Line <br /> SEEPAGE PIT [ Depth <br /> J <br /> ,,,,,_ -: .. ......... Diameter ---------------- Number ..--.----.- ----------- .... Rock Filled Yes ❑ Na ❑� <br /> ` Water Table Depth ...�.�_j- .�. ...........::.......Rock Size ........_...... <br /> ..._._ <br /> f Distance to nearest: Well -...- . Foundation .................... Prop. Line --- .................. <br /> _ k ......... . - <br /> REPAIR/ADDITION(Prev. San+totion l <br /> Permit .................".--.------ "--- Ddte.-------.--.-----.• <br /> Septic Tank (Specify Requireme ts) _--.. .......'-.. t IN"_ .,t ....._..-- <br /> ---------------- <br /> Disposal Field (Specify Requirements <br /> -•------.-- -----------------­­ _ <br /> ...... ........................... .......------- <br /> ...._ .... <br /> (Drdw existing and required addition on rd'verse side) <br /> I hereby certify that 1 have prepared_ this application and that the workI will berdone 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: i <br /> "I certify that in the performance ofthe work for which this permit is issued, I shall not employ an <br /> as to become subject to Workman's Compensation laws of California." P .R any person in such manner <br /> Signed ._.... ...__......... . . ..... ........... Owner <br /> By _-" Title . <br /> (if oth ow�nr�eri ,Oko ............................. <br /> / F DEPARTMENT USE ONLY l <br /> APPLICATION ACCEPTED BY <br /> DATE _. /G. .-.7�'.......... i <br /> BUILDING PERMIT ISSUED _-- ......... .. ... �---�-- <br /> - -............. <br /> DATE ........_............. <br /> ADDITIONAL COMMENTS ------------------- ------ ----- <br /> ........................ ............ <br /> ................. .................................. .......... .............--------------------- -------------- .......... <br /> Final inspection by: ..._ .. ._�..,•:. ._. _r/ <br /> Date �/��7� .------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />=E. H. 1.3 24-1.'68 Rev. 5M _ <br />