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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> I 1------- --------------------------------- <br /> Permit No, .7 -- �i-------------- <br /> (Complete <br /> (Com lete in Triplicate) <br /> ----------- <br /> - This Permit Expires 1 Year From Date Issued Date Issued -__.---------------- <br /> Application <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 .CENSUS TRACT ----- 41:�l -- <br /> Owner's Name ------%:74=)JA ----- -------------------------= ----------------=---------------------Phone <br /> Address -------1--:3- 2►� W' �t;'7"J� .ji4 _ ----zt)------------ -- City _. ` �r -----•----------------------------•-----------••- <br /> Contractor's Name ------ r--------------------License # ------------------------- Phoner--------- <br /> Installation will serve: Residence Apartment House-❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑ Other __ '---------------------------------------- . <br /> Number of living units:----- Number of bedrooms __+_----Garbage Grinder .__._`s----- Lot Size ----1___�y-----------------------•- <br /> .Water Supply: Public System and name ---------Q_�..AVA --.------VJE�----------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand-'[] Silt❑ Clay ❑ Peat❑ Sandy Loam-'9_ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type _______________---_-_____ <br /> (Plot plan, showing size of lot, location ofsystemin 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,) a <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![r] Size--------l-_?,0.0---4Sfih-_L--------- Liquid Depth --------------------------- <br /> Capacity ---1_'WO.__. TypeMaterial_CAS -:-,Ce:_ No. Compartments ___'�------------- <br /> Distance to nearest: Well _________� __________________Foundations-__.11_"--_ Prop. Line __4 .......------ <br /> IF <br /> LEACHING LINE [ ] No. of Lines -------- -------- g t <br /> Len th of each line.______!C_C�__.______ Total Length <br /> ---'D-' Box Box•C-A.-g--GType-Filter;Material„ ........._Depth_Filter Material'.-------i,_ --------------- -•--------•---- <br /> Distance to nearest: Well --------SO----------- Foundation ------_0------------- Property Line _-___ 7______________ <br /> SEEPAGE PIT [ ] Depth __--------------------,Diameter -------------__--_Number _..__ ------------------- Rock Filled Yes ❑ No C] . <br /> Water Table Depth ------------------------------------------------Rock Size -------------------- --------' <br /> Distance to nearest: Well -------- _______________ _______ Foundation -------_______.____ Prop. Line --------------- ...... <br /> i REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-___________________-----1 <br /> 1 <br /> Septic Tank (Specify Requirements) = - ------------------ --------------------- ------•1----------- <br /> Disposal Field (Specify Requirements) ------------------- -------------------- ----------------------------------------------------------------------------------- <br /> -------------------- <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 Distrid.,Home owner or licen- <br /> sed agents signature certifies the following: `T <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 <br /> 'toq Workman's Compensation laws of California." `* <br /> Signed _VW--.0 --------------------------- Owner <br /> By ------- ------------------------------------------------------- Title --worZV <br /> (If other than owner) <br /> FOR DEPARTMENT USE,ONLY <br /> APPLICATION ACCEPTED BY -------------------------------- ---------- ------ -- - ------- -�r -A------. DATE -'--IV-?----- ---------------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------- -- ------ ------ --------------------- ------ - ----- --------------DATE - ----------------------------------------- <br /> ADDITIONAL'COMMENTS -------------------------------- ------ ------------------------ ----'--- ---- ------- -------------------------------- --------------------------- <br /> -------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------- <br /> -------------------------------------- ---- <br /> FinalInspection by: ------------------------------------------------------------------•-------------------- -------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTo <br /> E. H. 9 1-'68 Rev. 5M <br />