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FOR OFFICE USE: - ;. 4 <br /> APPLICATION FOR SANITATION PERMIT. y <br /> --------------�--------------------- R Permit No: �:� �-�� <br /> (Complete in Triplicate) <br /> __-_______------------------- --------------- This Permit Expires 1,Year From Date Issued <br /> Date Issued . -�� <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Qrdinance No. 5492d existing Rules and Regulations: <br /> JOB ADDRESS/LOCA N ---------- --- ------- ......... <br /> uk----(-?&-A-k410ENSUS TRACT -------------------------- <br /> --------------------------------------------- r--------Phone ---------------------------- <br /> - <br /> Owner's Name _- _ - _ _ --_________ <br /> Address °� - ------- "'� ` �---------- -----------• City <br /> (',, - �- � <br /> Contractor's Name ------poqo------- -- "— -------------------------License # �.: - - Phone��----.... <br /> Installation will serve: Residence]Apartment House❑ Commercial ❑Trailer Court ❑' <br /> Motel'❑ Other ------------------------------ <br /> Number of living units:----1-------Number of bedrooms _____Garbage Grinder +_ Lot Size _1 08- _A___ _______________ <br /> Water Supply: Public System and name ------- - ;Private <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ s Clay Loam ;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ �. <br /> (Plot plan, showing size of lot, location of system in rBlationsto wells, buildings, etc. must be placed on reverse side.) J <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 Compartments ---��_�__________.... <br /> Distance to nearest: Well ------- ________________Foundation _,___- ®_ -_ --_-_ Prop. Line ____._tj ____ <br /> 4 LEACHING LINE No, of Lines -------3------------- Length of each <br /> �line-��--?a�__rld_ Total Length --�`f- <br /> 'DBox'�f P --- Type Filter Material �C c.�---_--__Depth Filter'Material ;___ - -___________________________________ <br /> I Foundation Property - <br /> Distance to nearest: Well �------------ ---1__- ------ Proper Line - ---------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number -------- ------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ----------------------------------- ------------Rock Size ------------------------------ <br /> Distance to nearest: Well ----------------------------------------foundation <br /> --------_------------ Prop. Line ----------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ::__________-:________-_________-1 <br /> SepticTank (Specify Requirements) -------------------- --------------------------------------------- ------------------------------.-_ :-•-----=-------------------- <br /> Disposal f=ield (Specify Requirements) ---------------------------------------------------------------------------------------'-" i <br /> ------------------------ <br /> ------------------------------------ ------ ---------------------------------------------------------------------------------------------------------------- -------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I hav� 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -----------"--- --_'� "' f __ Owner <br /> t . � -- <br /> BY -------------- - --------- �.J�J ----------- ; Title ----- -&&,-s --------- ------------------------ <br /> (If other than o <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------- ------------------------------------------------------------ DATE 7/2 --7-------------------------- <br /> BUILDING PERMIT ISSUED -=----- ---- -------------------------- ---- <br /> --------------------------------------DATE - - --------------- ------------------ <br /> ADDITIONALCOMMENTS -' .- ---- -- ---------------------------------------------------------------------------------------------------------- --------------------------- <br /> --------------------------------------------=------------- <br /> ------------------=--------------------------------------------------------------------------------------------- <br /> 5 <br /> ________________________________ ____R_ -_-- - _ _ _----------_ __--___-____.._-_____ <br /> Final Inspection b --Date 9 zz�7 <br /> ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />