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FOR OFFICE USE: t` <br /> APPLICATION FOR SANITATION PERMIT Permit-- - - -----------------•-- Permit No. --- --- ---- <br /> ---------- <br /> p Triplicate) <br /> - - -- ------------------------------------------- This Permit Expires ] Yea <br /> (Complete in T 9V17:0 <br /> j / /J <br /> --------------------------------------------------------- p r From Date Issued Date Issued __.9V17-�J/ f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and instoillthe wwork. er in . E <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rgls.and`Regulotions: <br /> JOB ADDRESSAOCATION .± r ----- -------- --- ��'- _-- -- --- �4------------CENSUS TRACT .--- -_---___--._ <br /> Owner's Name --- _Zd/l.A Vne-1 ------------------- -•--- -------15110 - - -""' -__ <br /> _- -Cit --- <br /> Address �_�6„�-=- - - -- ------ ------• ------ ----=--------------------------------•--• Y �"` '� ---------------------------••---•- � <br /> Contractor's Name ------------------------------------------;--------------------------License # ----- Phone ---------------------­------ <br /> Installation <br /> ^." -.- ....Installation will serve: -Residencet Apartment House-[] Commercial :❑Trailer Court '❑ <br /> Motel ❑ Other ----------------------------------- /} <br /> Number of living units-1__Y_�Number of bedrooms 2!�-_,—__Garba.g#:�Gri ------- of Size 6 J�� ___________________________ <br /> Water Supply: Public System,apd€names-- --------------------------------------------------------- --------------- ------ - ............-Private <br /> haracter.bf-soil-T-S a -ept -of 3 Fee"t: Sand�Q Silt °"'"Clay � eat Sandy Loam ❑ Cla'y�o m ] <br /> Hardpan IV 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 --------- -------- Material-------- ------------- No. Compartments -------- -------- <br /> Distance to nearest: Well ---------------------------------------Foundation ---------------------- Prop. Line ___________________ <br /> LEACHING LINE [ J 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 PIT [ ] Depth ____________________ Diameter ________________ Number ----------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---------------- - <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation permit# --------------------------------------------- Date ---------------------------------- <br /> Septic <br /> ------------=-_----------------_Septic Tank (Specify Requirements) ------- •------------- ----- -•----•------- -----------------------------.-,f •----------- <br /> Disposal Field (Specify Require ents) €+�" '"�_ ... ' __:___ _-_-_ ______ _ � _.'f. a---__ _ <br /> -- - <br /> --=� ,✓ T .r —.�....+�+rr-,rte x. _ .+...��,` _�- _.�^�s:.:w-�._ — �r wya�T <br /> -------------------------------------------- ----- -------- ---------------:----------�---------------- --------------------------------- <br /> -----= - ------ ------- <br /> (Draw existingand 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 thisermit is issued, I shall not employ p p y an y person in such manner <br /> g to be" Wo an s mpensatiop,laws of California." <br /> Signed e---0- t- . . ----- --------- Owner <br /> By ----------------- --- -tr ------------------------------------------------------------------ Title ------------------------------ <br /> ----------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE fp <br /> ------------------- <br /> BUILDING j <br /> PERMIT ISSUED ---------=------------------------------------------------- --------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------I----------------------------------------------------------------------------------------------------------- --- ---- ----- <br /> -------------------- ------------------------------------------------------------------------------------------------------------------------------- ------- ------------- - ------- <br /> -------------------------------------- - - <br /> ----------------------------- --- �� ! - -----`------------------------------------------------------------------------------------ ----- <br /> Final Inspection by: -- ----------- -- --- ---- Date% — <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M a g <br /> r <br />