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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ; <br />...................................................... Permit No. /7 .: ._ <br /> IComplete in Triplicate) <br /> .............................................._ v. ... <br /> .............•...................... This Permit Expires 1 Year From Date Issued Data 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/LOCATION ... . sY. ...... Pte! .---r . ...........CENSUS TRACT .......................... <br /> Owner's Name . t� � Phone . . �_•. ....... . --- <br /> ---- -�z <br /> Address .1_ __ City ... <br /> -... .. .. ......... '....... <br /> -- ----- --- - <br /> Contractor s.Name '"' S° �1---- ---...License ..��f� .. Phone ""' ..../... �T_ <br /> ---- -------------• ------------------- -- - -- <br /> I-A <br /> Instaliation will serve. Residence Aparrin ent.Hou`sefl Commercial QTraller Court,0` <br /> -Ai- <br /> Motel.Q Other-:.......................................... <br /> 7 11 <br /> Number of )juin units•..._. Number of bedrooms Garbage Grinder ....._..:::. Lot Size <br /> g F #.. ... .... .... .._._.... <br /> Water'Supply: Public System and name -•--•------------•.---•.......-•-.._........... ............ ..•----............._._. __....:.....---.... <br /> - Private <br /> Charactr.of-soil-to.a-depth.of-3..feet;- Siind.13—Silt El -..Clay.-Q-.-•.Peat.0.--Sandy Loam-C3:—Clay-Loam Q <br /> , } ,_„_,,,Wardpan Q Adobe 0Fill Material ............1f yes,type...........:... ............ <br /> � 5 <br /> - 1 <br /> (Plot plan, showing size.-of -iot,.location of system In relation to wells, buildings, etc. mud 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 f ] Size......................................::........ Liquid Depth'---------- <br /> .......... <br /> ..-_-- <br /> 1 � <br /> Capacity.. •--- ---••---•-- Type -• ---------- ----- Material-----------.-__.. -A No. Compartments ----....... ..........JI <br /> € -i;,w . <br /> Distance.,to nearest: Well ....................................Foundation ...................... Prop. Line ..._.......... ....... l� <br /> .............LEACHING LINE ,,,,[ J No. of Lines _.:..._...._�:....•-.... Length of�each line............................ Total'Length __ ............. - <br /> D' Box ...71.5`'•':-Type-F er-Material ..:.. "........Depth Filter Material ............... ...................... <br /> -Distance to nearest: Well ---------------•-- ......Foundation.. ............. ........-Property--Line- .. l <br /> LIW <br /> SEEPAGE PIT [ }r Depth t:. ._ :` Dinmster - -------------- Number ............._.... ........ Rock Filled Yes Q NO <br /> W <br /> 1 ater Table�D,epth._" .T.........__�........:..................Rock Size <br /> -----••.................. <br /> Distance to nearest: Well.,.... ...Foundation .......... Prop. Line -.. ...- <br /> �' <br /> ' WAIR/ADDITION(Prev. Sanitation Permit# �` .......... Date ... ':t`L)L 1 I. <br /> E <br /> Septic Tank (Specify Requirements)'.......... •----....a, ...... ......... ..-....... •_. ...................•--- ............... <br /> Disposal"Field (Specify. Requirements) ...•-- "f"'�_-._ _ . .. 'G�--r• ------------- <br /> +J` --- f....]i..r_ --�O'•-_-.... ..._cc.�=�-r3 - -•-•S --e...................•------ <br /> , <br /> - ___ <br /> (Draw exisfing and required addition on reverse sldeI ' <br /> ! hereby certify that I have p�epiared this application aet 'that-thvvork will"be`slone in accordance wish San Joaquin, i <br /> County Ordinances, State Laws, and Ruler and Regulations of the San Joaquin Local Health:Olstrid. Home owner or licen- <br /> sed agents signature certifies the following' r - <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 Workman's Compensation .laws of California." <br /> I Signed ------------------------- - ---- ------------------ Owner <br /> BY --------------- - --- -�4h �ww <br /> ...... -------- <br /> Title ------ <br /> ...... 6-.._.....--------.....................---•-- <br /> il o nerl r <br /> FORIDEPARTMENf'USE ONLY-\ <br /> APPLICATION ACCEPTED 8Y _ _.-- -- . .- -_. .f - Z <br /> ©ATE 7 <br /> BUILDING PERMIT ISSUED ...---- -------------------- <br /> -••-•--•--••----• I-------••-------------------•--•---------DATE .... -------- .-...............--_.°-- <br /> ADDITIONALCOMMENTS ..... .. ........--------._--_------_-----------------•---- -•-'--•------- ---------------...----.....•---------------------.._._.:.........................-- <br /> ------ --- -------- ------------------------------------------------------------------ -------------- ............. .......................... .............................. <br /> -------- --•--------- -----•-•- ---------------------------------- ...................--------...._....:.. .._........ .........._.. <br /> ------------- ----------------- .. . ..................................................... -............................ <br /> FinalInspection by: ............... ....... .. .. .. .................................................... ------- ---. --.-.---- ---Date ....:-- - - ........... <br /> EH 13 .24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M <br />