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I <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- ------------- -* <br /> Permit No. -4 <br /> (Complete in Triplicate) <br /> ---------=---------- ------------------------------------ <br /> +-------------- This Permit Expires 1 Year From Date Issued Hate 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 .-/ ------ . ./4?' -- --------------- ---- ----- ------CENSUS TRACT --------------- ---------- <br /> Owner's Name 7 � Q '4 - S ----------------------------- ------------------------------------------------Phone <br /> Address --5Y � � - _ r <br /> /}/h(�"--------------- - -------•-------------------- -------------------------• Cit _._..5- / Com-/ ----------- -------------------------- -- <br /> Contractor's Name ._ /�/� -�`-----.S;-7-S------------------------------------------ --------License # l �[3 0 Phonei '_�ri <br /> ry <br /> Installation will serve: Residence [`Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units: ----)---- Number of bedrooms ---.?_---Garbage Grinder/XV-.0 Lot Size ---l0--G------------ <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: i Sand'❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> r - <br /> Hardpan ❑ Adobej& Fill Material ------------ If yes, type ----____----.-----_------- <br /> (Plot plan, showing size of lot, Iocation,_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 [ I SEPTIC TANK'[ ] Size-----------------------------------•------------ Liquid Depth --------------------------- <br /> Capacity ------------------- Type -------------------- Material---------------------- No. Compartments --------------...:---. <br /> Distance to nearest: Well ------------------------------------Foundation ------------------.--- Prop. Line ---------------------- <br /> LEACHING <br /> -------- ------ t <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- <br /> 'D' Box ------------ -Type Filter Material --------------------Depth Filter Material -------------------- A <br /> Distance to nearest: Well ------------------------ Foundation ------------- ------ Property Line. ----------------. --.-- � <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes o No 0 3 <br /> WaterTable Depth --------- --------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) ' <br /> F <br /> Septic Tank (Specify Requirements) ------/�0-0--------6A -- PW' -t �` � - 4c, ------------------------ <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 shall not employ any person in such manner <br /> as to becomes Iect to Workman's Comp en tion laws of California." <br /> Signed ------ --- �--'� C/ ----- <br /> Owner <br /> BY --- ------------- ---------- --------------------------------------------- -Title --------- ------------------------ ------- ------------ --------------- <br /> (If other than owner) <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ---- ----------------------------- DATEr-w���—/— -4f <br /> BUILDING PERMIT ISSUED -------- / DATE ------------- --------- -------- <br /> ADDITIONAL COMMENTS ------------- -- `----------------------------------------------------------------- ---- <br /> ---- <br /> ------------------- ---------------------------- ------ --- --------------------------------------------------------------------- ------------------------------ ----------- <br /> - <br /> - -- <br /> - ------------------------------------------------------------ ------------ -------- --------- ----------------- <br /> ------------------------------------- - -- ---►- - ------------------------------------------------------------------------------------------------------- ------------------------------ <br /> FinalInspection by: - ----------------------------------------------------------------------------Date - = =/ -----------------•------- <br /> x <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />