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FOR OFFICE USE: <br /> s) APPLICATION -FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. 73-a-3 9 <br /> ---------------------------------------------- <br /> z._.&---_ This Permit Expires 1 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�s?__ S__ _._ l /l_ __ 1 �T___ 6 .CENSUS TRACT --------------_--------- <br /> Owner's <br /> ______________ _. -- _Owner's Name ------ , i S �jJfu l f / f------------------------ - Phone <br /> --------------------------- <br /> y <br /> Address fQ �°" f�`� �?r Citczx C - <br /> Contractor's Name - �- ---.License # � ��-. Phone ------------------------------ <br /> Installation will serve: sidence 7partment House❑ Commercialrailer Court <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms _________...Garbage Grinder _-------- -- Lot Size l�� -----�_'_________-._. <br /> Water Supply: Public System and name -----------------------------------­ - ---------------------------------------------------- -----------------Private <br /> Character of soil to a depth of 3 feet: Sand le Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .[] <br /> Hardpan ❑ Adobe ❑ Fill Material ___________ If yes, type ---------------------------- <br /> (Plot <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,] �0, i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size__________ X...9___--------- ---- Liquid Depth ----- --------- <br /> Capacity ---1Z.Q0----- Type 4p, £_427`Material_____ ____ No. Compartments ----- ":..__.__ <br /> Distance to nearest: Well -------1-00 ------------ Prop. Line -----S!___......_ <br /> LEACHING LINE [ ] No. of Lines -------/------------- Length of,?ach line____-100------------- Total Length AO6........... <br /> r� fr <br /> 'p' Box _ ._ Type Filter Material Depth Filter Material -----/ ____" _------________.__-----_- <br /> Distance to nearest: Well __ , ___________ Foundation ____. . Property Line. _____-1 ------ <br /> SEEPAGE PIT [ ] Depth ------ --- ------ Diameter ---------------- Number ________'____. ------------- Rock Filled Yes ❑ No .0 <br /> Water Table Depth ---------------------------•--------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) ------------------- ----------------------••----------------------------..--------------------------- <br /> Disposal Field {Specify Requirements) -----------_--------------------------------------------------------------------- --------------------------------------------- <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 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, I shalt not employ any person in such manner <br /> as to become ' ct to ork on's-C mpen tion laws of California." <br /> Signed --- ------ - - ---- ------ Owner <br /> - --- Title ------------------------------------- ---- ---- ----------------------- <br /> (If other tha ow <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ -- - - -- ---------------- ----------------------------------------------------------------- DATE 7--- ---------- <br /> BUILDING PERMIT ISSUED --------- - --------------------------------------- ------------ --------------DATE ------------- ------------------------ <br /> ADDITIONAL COMMENTS -- �� W � _- -------------------------- <br /> ____:__ _____--------------------------- __ _=_____:_ - _________- --------------------------- <br /> -- <br /> ----------____ __________ ___________ _____ <br /> ____ - -- - - ---- - ---- _ ______ <br /> i . <br /> Final inspection by: ---- ---- ---------------------------------------------------------------------------.Date -- --- <br /> - <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />