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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ;7:7 <br /> ------J (Complete in Triplicate) Permit No.. <br /> ----------------�.:7 <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 per'mit 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 /> 0'J !ADDRESS/LOCATION --------- 60-CENSUS TRACT ---------- <br /> B ----- <br /> Owner's Name ------ ------------------------------------------------------ -------------------Phone 1?9 <br /> I - 5 'P�_ <br /> cl,�s,t 14��-_7ps -------(��_-- ----A- / <br /> Ad -1-------- City 6341-k------------------------------------- <br /> -cy -JZ Amp-s-, License # ----------- ------ ----- Phone <br /> Contractor's <br /> or's Name <br /> Installation will serve: Residence Apartment House E] Commercial :E]Trailer Court iF] <br /> Motel M Other -------------------------------------------- <br /> Number of living units:---- ------ Number of bedrooms _____'__Garbage Grinder ------------ Lot Size -_____________________ <br /> Wate'r Supply: Public System and name ---- ----------------------------------------------------------------------------------Private <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay E] Peat 0 Sandy Loam ,E] Clay Loam <br /> Hardpan E] Adobe-[:] Fill Material ------------ If yes, type ---------------------------- <br /> (Plof,plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW41SISTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) OQ <br /> PACKAGE TREATMENT, SEPTIC TANK[ I Size----S---x---�7------ ----------------------- Liquid Depth _1 ..... --------- V1 <br /> CapqCapacity -I - - _ ------ Material__Lv7u-_,------ No. Compartments ---fZ...............- ---06--------- Type -Ar_9.r- <br /> Distance to nearest: Well ------------------------------------Foundation ---- ----------------- Prop. Line ----------_------ <br /> LEA:CHING LINE No. of Lines --------21----------- Length of each line___/0.V--------------- Total Length ......... <br /> 'D' Box _---I------ Type Filter-Material-_,Z)_f'-- ----Depth_.Filter Material­_-/W----r-- <br /> --------------- ...... <br /> Distance to nearest: Well ------I------------- Foundation -____.___-__1_----=-Property--Line---------------- ........ <br /> Depth ------ Number ------ - ---------------- Rock Filled Yes o C] <br /> SEEPAGE PIT .11-01------- Diameter '-.L <br /> Water Table Depth -------------`-------------t-----------•-----..Rack Size --------------------------- <br /> -------------- ---� Prop. Lin' <br /> Distance to nearest: Well -------------------- ---------------.---Foundation ------------.'__' --------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -•----••---------------------------------=-- Date ----- •---- --------------------- <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------a---------------------------------------------------- ------------------------ <br /> DisposalField (Specify Requirements) ---------------_I--------------------- -------- -------------------------------------------------------------------I--------------- <br /> ------------------------- -------------------------------------------------------------------------------------------------- --------- ----------------------------------------- ------------------------ <br /> ------ - ----------------------------------------------- --------------------------------------- ------------------------------------------------------------------------ --------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done iniaccorclance 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, I shallsnot employ any person in such manner <br /> as to'7become subject to Workman's Compen3ation laws of California." <br /> :igne'�--------------------'i------------------------------------------------------- ------------. Owner <br /> 1 - <br /> By 16 �1_/ <br /> I I Title -------------------- e��-------------------------- <br /> ------Z-- ---- --------------------------------------------- - 7 <br /> Ilf other than owner) <br /> 1eZZ__ZQ,1E1 PARTM ENT USE ONLY <br /> - 71---- ------------- <br /> APPLICATION ACCEPTED BY ------ - --------- ------------------------------------------ ------------------ DATE 3-74�� <br /> BUILDING PERMIT ISSUED --------- - --- ---- --------- ----------- -------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COM NTS --- 1( --- - ------------- --- -------- ------- <br /> ----- ------ --- -------I-- --------- <br /> -, - -a/ --- -- --------A_�I_Xl <br /> ----- --- - - ---- -------- - ------ <br /> - --------- - - - -------- -OL ----- ------------------------------------------------------------ <br /> -- --------- -- ------------ -------------- ----------------------------------------------------I------- <br /> Fin'al'Inspection by: - -- - -------------------------------------------------------------------------------------Date 2-:7 <br /> ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'E. H.:9 1-'6$ Rev. 5M, <br />