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FOR OFFICE USE:- <br /> APPLICATION FOR SANITATION PERMIT <br /> 1___________ (Complete in Triplicate) Permit No. _.7_Z__�__ L <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 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 /> ` JOB ADDRESS/ TION --.,_7��--- :--_e.- �----------------------- <br /> CENSUS TRACT <br /> oip <br /> ` Owner's Name -_. ----------- ---------------------Phone ---------------- <br /> Address ----------=----F-7.� - ---- --------- -------------- City --- ---------------------------------------= <br /> e <br /> Contractor's Name -----A-2 -- ------ ------ _.License #/ __8Phone ------------------------------ <br /> Installation will serve: Residence R-Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ------------------------------------------ <br /> i Number of living units:------f----- Number of bedrooms --- -----Garbage Grinder ------------ Lot Size ---Q __________ _____ ________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet:_ Sand'[:] Silt E] Clay El Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> Hardpan Adobe 0 Fill Material ------------ If yes,type --------------------------- <br /> (Plot plan, showing size of lot, location of system in relation t'o wells, buildings,,etc{must be placed on reverse side.) <br /> j NEW INSTALLATION: (No septic-ton k,or,sefeet,) <br /> pit permitted if public sewer is available within 200 feetV <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size__ ~ <br /> Liquid Depth - d <br /> Capacity,_�9-4__k__ Type G-_: Material-- <br /> . ._ �....__ No. Compartments -__--__a_�_ <br /> f Distance to nearest: Well -----------�d �---------------Foundation ------ /_Q_-_I-__-_ Prop, Line <br /> LEACHING LINE [I,/ No. of Lines -------- ----------- Length�of each line_____ -------- Total Length ,____ P.0....... <br /> .. <br /> 'D' Box __:__l.:__'"Type Filter.Material ----- ------ Filter Material ---------Iq <br /> Distance to nearest: Well -------4��--------- Foundation -------/_b-__________ Property Line ----- ............... <br /> SEEPAGE PITt Depth ______0"2_T! Diameter ___ __y Number --------------off..-------- Rock Filled YesNo <br /> Water Table Depth -------------go.- -----------------------.-Rock Size <br /> Distance to nearest: Well -----------hgo- ---------------Foundation _____/a_.......... Prop. Line -------- --------- <br /> REPAIR/ADDITION <br /> ---__-__REPAIRJADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> -----------_---------------------Se tic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•--------------- <br /> -. <br /> _ <br /> ------- -------- --------- -- - - <br /> `� }(Drawexisting-and required addition=on reverse-side)—­ <br /> I <br /> everse side)--•��--4 ­ <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------- Owner <br /> BY 1 r ------- Title -- --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYE� �- -------------------------------------------------------- DATE -- _7 _77 Z----------------- <br /> BUILDINGPERMIT ISSUED --------- --------------------------------------------------------------------- --------------DATE -------------------------------------- <br /> ADDITIONAL COMMENTS <br /> -----------------------------------------------•------------------------------------------------------------------------------------------------------------------------- ---------------- -=------- <br /> ---------------- - <br /> �4Z <br /> Final Inspection by: = ------------------------------------------------------------- --Date — <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />