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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- --- --- --- ------------------ --- <br /> (Complete in Triplicate) Permit No. ---------------------- <br /> ---------=----------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Z�­_"/6'-, <br /> D(" 9-v81-0--I <br /> Application is hereby made to the San Joaquin Local Health District for o 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 /> ( <br /> 513� w E 1 C-4--i j h(tj _.,P.ar 4 <br /> JOB ADDRESS/LOCATION ---P4GI6c--e------Xr 4_c✓---_/1L'c�11- .S Td c,___.//CENSUS TRACT -------------------------- <br /> Owner's Name -- c¢ _ { ���c fc4'�. tyta`-iii Phone ._.49�/_ V ic; 7y <br /> - --------------- <br /> Address ._ _cac--- ------ - � est. City -S Toc. Tari <br /> Contractor's Name - --- -.- - ---------.License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial XTrailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- f- <br /> r1 j2 7� wt <br /> 1 rCi`i�clah r'n rs a gra <br /> Number of living units:._ Number of bedrooms --- Grinder Lot Size -------.Resos^f`__.Cf_t^_c�q____ <br /> Water Supply: Public System and name --------------- ------------------------------------------------------------------------------------------- Private ` _ •. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam F1 <br /> Hardpan ❑ Adobe ❑ 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 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK&( Size-------- ----- _______ Liquid Depth __________________________ ►- <br /> Capacity --------------------- Type ---------------------.Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well ______________ <br /> ---------'------------Foundation rad-/ --- Prop. Line ---- -•----- s%� <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line-------------------------.__ Total Length ----------- <br /> 'D' Box -----------. Type Filter Material ___________________Depth Filter Material --- -------------------------------- , } <br /> P <br /> Distance to nearest: Well ----�_------------f__._ Foundation _____, ______- Property Line ___ ....... <br /> Id )c too <br /> _QffEM0&4nT [ ] Depth ------------------- ------ Number -------------/------------1Rock Filled Yes No 0 <br /> n Water Table Depth -------------------- 57_�'--------------------Rock Size <br /> Distance to nearest: Well __________ _�Od_________________Foundation _____---- .___ Prop. Line _._ r.�........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------- ----------------------------- <br /> e <br /> Disposal Field (Specify Requirements) - -_s_._.... -----------_______________Q r_____--I-� <br /> ----------- <br /> y <br /> - � ,5--- ---- -:: --.+✓-----fir -- -----------"-" � -- ---- ----- -- ------ ------------------------------------------------------ <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: a <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." i <br /> Signed ------------------' Owner L <br /> BY ------ ------ Title <br /> ----------- <br /> --------------------------------------- <br /> (If other than owner] <br /> FOR D PAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY ______________ -______- DATE ____7._f4- _7a_____.__-__ <br /> ------K <br /> ----------------- ----------------- <br /> BUILDING PERMIT ISSUED ------------------------ ---------DATE ------- ---- --------- --- ---------------- <br /> ----------- --- ---- --------------------------------------- <br /> ADDITIONAL COMMENTS ----------- <br /> �"" �-Q' ' <br /> --------- --=- ------- <br /> --------- ------------ <br /> ----- a] '7 a-- --------------------------------- ----------------- <br /> - - - - - - - <br /> ----- <br /> Final Inspection by: --- � .. €�. _ L _ ate ------- ------ <br /> SAN JOAQUIN LOCAL HEAL H DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />