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FnR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---��-• -- - ----------------•-------- - Permit No. <br /> (Complete in Triplicate) <br /> ,• _---------------------- ---_--------- <br /> Date Issued .5 -_�y_V <br /> ------------------- - This Permit Expires 1 Year From Date 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 �lw'/ � _ - __-- # - --------------------------CENSUS TRACT -------------------------- <br /> Owner's Nac-'1��.��--------------------------------- ------Phone <br /> --'C� `�`� City - - <br /> Addres� r <br /> Contractor's Name _,�l - �- 4t_______.License # L?_ --- ---------- Phone <br /> Installation will serve: Residence;KApartment 4use�❑ Commercial ❑Trailer Court ,❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Numbar of living units:..----. -_- Number of bedrooms _.-------Garbage Grinder ltd_____ Lot Size _ _d_r----__1"` __----' <br /> Water Supply: Public System and name ----------------------------------- --------------------- ---•----------I----------------------- -------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 14 Fill 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 fget,l N-1 <br /> PACKAGE TREATMENT { ] SEPTIC TANK ik Size____ ___ q p f� '� <br /> ,P.f.__--_X -"--- Li uid De th --�- .. <br /> No. Corn artments _^ti._____. <br /> Capacity J1C'8� _-- Typ a�A.e _ Material No. p •----•--- <br /> 4 ..-__-______ _- --Foundation --- Line_, Pro Line -------_'2,J_ ._ <br /> Distance to nearest: Well __�_______ _r _____ �', p. �-- <br /> LEACHING LINE X No. of Lines 4-� ----- Length of each line�0- "�Ca-`t' ' Total Length. <br /> 'D' Box -----t----- Type Filter Mated aL� __Depth Filter Material _Q_----__________________________ <br /> a ._ <br /> ,hQ__._._.._'__ Property Line r <br /> _ Distance to nearest: Well-:�i_L�1;__t__�-m_ Foun ation __ ------- � <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------- --------------tRock Filled . Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -------------- ' <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------- ........ <br /> REPAIR/ADDITION[Prev. Sanitation Permit# ------- ------------------------------------ Date -----------------------'_-----____-} <br /> SepticTank (Specify Requirements) -------- --------------------------------------------------=---------------- ---------------------------------- ----------------------- <br /> Disposal Field (Specify Requirements) ---------------------------•---•---------------------------------------------------------------------------------------------------- <br /> ------------------------- ---------------- ---------- -- -----------------------------------------------------------------------------------------------------------------------1------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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: ` <br /> "I certify at in the performance of the work for which this permit is issued, I shall not employ any person in such manner i <br /> as to be a subject to Work 's Co Rensatio laws of California." <br /> Signed ` F vt! - --------cehrmm <br /> ' <br /> BY ... -------------------- ''` Title Q'. <br /> (if other than owner) <br /> FOR DEPARTMENT USE ON <br /> APPLICATION ACCEPTED BY --- ---- -------------------------------------------- -------- __ �?t DATE <br /> BUILDING PERMIT ISSUED ------------------------------------------ --------- ------------ --- -- - #=--DATE --------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------- ------ ------- ----------------------------------- -t -------- ------------------------------------------------- <br /> ------------------------------------------------------ ---------------------------------- ------------------------------------------ ------------------------------------ ---------------------- <br /> ----------------- ------------------------- ------------------------------------------------------------------------- --- ------ -- -------------------------------- ----------------------- <br /> -------------------------------------I------------------------------------------------------------------- <br /> -1--------------------- <br /> Final Inspection bY- -------------------- ----------------------------------------------- --------• _ � Date _S o - ------------------ <br /> ------------------------ <br /> SAN JOAQUIN LO AL ALTH STR CT <br /> E. H. 9 1-'68 Rev. 5M <br />