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FOR OFFI1 USE: <br /> _ 3 e APPLICATION FOR SANITATION PERMIT <br /> S �� Permit No: , <br /> -- ---------Eye - a. <br /> [Complete in Triplicate) <br /> ----------�- i- ------------------------------------------ <br /> This Permit Expires ] Year From Date Issued Date Issued <br /> -------------------------------------------------------- <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 - � I�_-- - -(/ _ -- - -----------------------`.......CENSUS TRACT -------------------------- <br /> Owner's Name -----/ L1.0 --------i75WgOs-------------------------------------------------------------------------Phone ---------------------­- ••- ••---- <br /> Address -----/3-/V-----A40_-/214------ALll __019/9------------------------- City -S `O C K7-61V <br /> Contractor's Name -..'1.. f ---------- .-�--- ------------ ------------------------.License # /7-7_i?.-... Phone ------------------------------ <br /> Installation will serve:` Residence qj-,A'partment House,C] Commercial ❑Trailer Court ;❑ <br /> 'Motel ❑Other ------------------------------------------ <br /> / d2 iV 4 . { / O <br /> Number of living units:-____--___- Number of bedrooms -__________Garbage Grinder �_--__--____ Lot Size _. _ ._-________.....________-__ <br /> Water Supply: Public System and name ---------------------------------- ---------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam f:] Clay Loam D <br /> Hardpan ❑ Adobe ill 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,J <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ I Size------------------------------------------------ Liquid Depth ---------------------.----- 4�,1 <br /> Capacity ----- -------------- Type -------------------- ,Material---------------------- No. Compartments --------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length -------------___-___-___--__ <br /> 'D' Box --------- -- Type Fitter Material --------------------Depth Filter Material -----------.--­ -------------------.--__-- <br /> Distance:to nearest: Well _______________________ Foundation - ---- ----------------- Property Line ________-._--_-___-_-_ <br /> SEEPAGE PIT [ ] Depth --- Diameter ---------------- Number -__- ---------------------- Rock Filled Yes [] No <br /> Water Table Depth --- ------ -------------------------------------Rock Size -------------------------------- .. <br /> i <br /> Distance to nearest: Well ----- ----------------------------------Foundation -------------------- Prop. Line ______-___--_.-_.__.__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- - ----------------- --------------- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) - -C? �r/��-------�OIU-- 7- <br /> ------------------ <br /> 1 <br /> Disposal Field (Specify Requirements) _1A1__1TjA1.1_---------r1s e?,Y----`--------7 -4"-0----------61-0-- -1 S------- I <br /> -------------- ------------------------------------------------------------I-------------------------------•-------------------------------------------------------------------- ----------------------- <br /> (Draw <br /> --------------------(Draw existing and 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: i j <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 becomes Iecf#o Work 's C pensation laws of California." <br /> --... <br /> Signed ' -.f-- -` <br /> --� -n�-----.__ __o_. r------------------------------------------- Owner , <br /> r <br /> BY -------------------------- ----------------------- Title --------------.............. -------------------------------------- <br /> (If other than owner) r <br /> � Y <br /> FOR DEPARTMENT USE ONLY ► <br /> APPLICATION ACCEPTED BY ------------------ -------------------------------------------- <br /> ----- ------ ------------------- ------------ DATE ----- J - ----------------•--- i <br /> BUILDING PERMIT ISSUED ---------------------------------- - ----- - `--------DATE -------------•-------- <br /> ADDI�.L-- OM-� g ----------—---------- �- --- ------------ ---------------- ------=------------------- ----------------------------------------- <br /> ---- ------------------- <br /> - ; = �. .. Com- <br /> ------------- ------------- ---- ------¢ - - - ------ --------------- - <br /> Date <br /> - -------=------- <br /> Final Inspection by: ---------- <br /> SAN JOAQUIN. LOCAL HEALTH DISTRICT ] <br /> E. H. 9 1-'68 Rev. 5M <br />