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FOR OFFICE USE: �I �.�� r � <br /> APPUCATION FOR SANITATION PERMIT <br /> - <br /> ------- ------- ------------------------------------- � Permit No. - �-------------'-� <br /> (Complete in Triplicate) <br /> _ _______________ This Permit Expires 1 Year From Date issued <br /> Date Issued <br /> Application is hereljy 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 /> !_(O �r'� �rt'r CENSUS TRACT - --- <br /> 6-1 <br /> - <br /> JOB ADDRESS/LOCATION -- _-- --------------------- - - -- j <br /> I i <br /> Owner's Nome -'-------------- ----- Pho a 7, <br /> ------------------------------- --- <br /> 3-6 <br /> V­e�ii <br /> ! �7Address ----------------------------- 1 c� ----- CityContractor's Name -------------- -._-_ fl _____---_-- ---- --License # ---------;-------------- Phone V�6"940_x. <br /> Installation will serve: Residence Apartment House❑ CommercialX❑Trailer Court <br /> Motel ❑ Other . =r <br /> Number of living units:.__.____ Number of bedrooms -_�AJl!._Garbage Grinder ____._._-.__ Lot Size i g ---------------- <br /> Water Supply: Public System and'name - -------------------------------V-----------------------------------------------------------------------------Private ❑ ; <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt C] Clay .❑ Peat ❑ Sandy Loam ❑ Clay Loam 0 <br /> II Hardpan ❑ AdobeFill Material ------------ If yes, type -----_-------------- <br /> (Pl'ot 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 bvailable'_within 200 feet,) <br /> it } u>v,r +a.r <br /> PACKAGE TREATMENT`[-I' SEP.rTIC1Tt,A�NK f ] � Size______________________Ey-'�-_��-_ +[liquid Depth -------------------- <br /> *� ;Capacity TYPe. =� Material ` No. Compartments <br /> ----------------------- <br /> _ <br /> Distance p to nearest: Well L`* --°�--_ ;._____________FoundationI____ '_ ------i---- Prop. Line ____5----_________ <br /> LEACHING LINE; <� - No.�of Lines _ 1 �__: °`. Len th of each line-_-____ _ Tota( ten <br /> [ ) - _� i....• .. 9.` �--------- -- Length ----------------------------- <br /> i --------------------------- <br /> D'. bx -----____-- Type. FilterMaterial'4 -----------�---Depth Filter Material -- ------ ------------------ <br /> j # <br /> Distance{to nearest: Wel! ________________________.Foundation --------- ------------- Property Line _________.______._._. <br /> ., <br /> SEEPAGE PIT- ..[ ] Depth_!(____ ____ -------� Diameter ______________F Number _________________________Rock.Filled Yes '(] Na_1[]+ ; <br /> Water Table Depth" 3__________—'------- _____ \_Rock Size -------------------------------- <br /> Distance <br /> _______________ <br /> Distanceonearest: Well -_.--...foundation -------------------- Prop. Line --------..___-..--..._ <br /> REPAIR/ADDITION{Prey. Sanitation Permit# -------•-------_---------------- ------ -- Date ------ ---------------------------I I <br /> Septic Tank (Specify Requirements) �L ----------- ------- <br /> r <br /> p p T Y Requirements) - -----i----- ------ r ��� r <br /> Dis o a� ! Field [S ecif Re uir -------- <br /> -----------------------:-::._------------ ------------ � - ---- T---------- �----------1------- ------ -- ---------------------- <br /> (Draw .�.r <br /> I� existing and required-dddition ion <br /> _ _ reverse side) /��� r �.%did <br /> I hereby certify that I have prepared this application and that the work will be done in ac rdance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance'hof 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 /> Y -f _ Title <br /> (If other an owner} <br /> �. FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY -- # ` - ------ ----- .-_-.__T _ _ #-- ---_-- ------- <br /> BUILDING <br /> - -BUILDING PERMIT ISSUED ----------`I---------------------------------------------------------------I---------------------------- -DATE ------------------ <br /> ADDITIONALCOMMENTS ----------- ----------- ------ ---------------------------------------------------------------------------------------------- ----------•---------------- <br /> al <br /> ----------------------------------------- -----------•----- -------------••------------•------------------------------------------------------- ---------------------------- <br /> ------ - � <br /> FinalInspection by- - ----- ----- --------- ---- - - -----------------------------------------------------------------------------------Date ------ + . <br /> �! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ii <br /> n <br />