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�"�"FOR OFFICE USE: <br /> 3 a APPLICATION FOR SANITATION PERMIT <br /> a" <br /> [i (Completein Triplicate) Permit-No.,.711 .1�___ <br /> ------- ------------- <br /> ___I1Date Issued <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, --- - :--;----------------, / Q l ---lae---------------------CENSUS TRACT ----------------- -------- <br /> ------------------------------------ <br /> ---------- Phone - --- <br /> Owner's Name [ <br /> / � T <br /> Address ----------------------- ---------- <br /> ----Iwi city /~� �� <br /> Contractor's Name � d --------- -----! r--- ---------------------License # ---. Phone <br /> Installation will serve: ' Residence Apartment House-❑ Commercial :❑Trailer Court ;❑ <br /> A <br /> ` Motel ❑Other ----------------------------- r <br /> Number of living units:---I�1------ Number of bedrooms ___3------Garbage Grinder Wa----- Lot Size --__-______________ <br /> Water Supply: Public System and name ----------------------•---------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a deptl` of 3 feet: Sand'E] Silt❑ Clay .❑ Peau Sandy Loam -❑ Clay loam,5 <br /> t I <br /> Hardpan ❑ Adobe-E-] Fill Material ------------ If yes,type ----------------.______,___ <br /> (Phot plan, showing sizef 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 f I SEPTIC TANK Size__ i[ ( �� li uid Depth _- .. . ... ........ <br /> Il' =T�--- - q P <br /> Capacity/,2 <br /> Q ___ TypeL Material �� ' No. Compartments c _._______ <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> i� <br /> LEACHING LINE VA No. of lines _---------------__ Length of each line__fZ?__._-.____.______.Tata) Length ___________ <br /> D� Box _�- -- --- Type Filter Material ,/j`O_� __Depth Filter Material __l ________........................ <br /> Di!stance to nearest: Well ------- ----------- Foundation ------------ Property Line _,S .____ <br /> SEEPAGE PIT Dep th ---------- <br /> Diameter _______________ Number ----------------------t---- Rock Filled Yes No <br /> ti..- + <br /> Water Table Depth ----- ------------------- - <br /> - ------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------.--------.--.. <br /> REPAIR./ADDITION(Prev.,Sanitation Permit`# ----_________________________________.____ Date __________________________________) <br /> SepticTank {Specify Requirements) --------------------------------- `---------------------' ------------------------------------------------ --------------------------- <br /> Disposal <br /> --------------------------=---------------------...-------------------------- <br /> Disposal Field (Specifyi Requirements) ----------------------------------------- --------------------------------- -------------- <br /> -------------------------------------------------------- <br /> ----------------------------- k <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 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 lOrkman's Co pensation laws of California." <br /> Signed --------------------- --------- -- - --- ----- -- -------------------------------------------- Owner <br /> C <br /> By ------------------ ----------------- ------------------------------------ Title -----------------------------------------------------------..----------- <br /> ( ter nl�owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / _. DATE S_���:--7,/---------------- <br /> -- ---- - ------------------------------- <br /> BUILDING PERMIT ISSUED'( ------------------------ -- ------------=--------------DATE -------------------------------------------- <br /> ADDITIONAL COMMENTS'l------- ------------------------------------------- <br /> --------------- <br /> --------------------------- -- - ----------------------- <br /> i <br /> ---------------------------------- - -- - - --------------------------------------------------------------------------------------------------- <br /> Final Inspection by: I - Date _ <br /> s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M.: C' <br />