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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -/s— <br /> Permit <br />................................. . .. <br /> Permit No <br /> (Complete in Triplicate) <br /> :......:...... �.. ._ ........._......... 1 7J <br /> • Date Issued ...._."...:�"..... <br /> This Permit Expires <br /> ires 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.,ls,made_in_compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ' -- •_........._....._.1-�`r ......__CENSl5 TRACT .. <br /> one .. .............••• ........ <br /> Owner's Name . 4? . .............. ........................................... -- <br /> ' r ` . City . <br /> ............. <br /> Address � - _.••-•--•- - ••- •� #nse 1 <br /> ......•..... _LicePhone .... <br /> .............................. <br /> Contractor's Nome ... ,i1-' -- -•-•• <br /> Installation will serve: Residence (ff/Aportment Housef❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ..............................:.............. i <br /> Number of living units:......... Number of bedrooms .Jam_.....Garbage Grinder ......_.__. Lot Size ............................................ <br /> Water Supply: Public System and name ................. .... ..--•.--.-•-.-••,•- -------•-..--..--- ................. Private <br /> Character of soil to a depth of 3 feet: Sand ❑ ilt❑ -Clay ❑ " Peat❑ Sandy Loam ] Clay Loam <br /> Hardpan [Adobe'❑ Fill Materia) ............ if yes,type ---------------- 99jj <br /> fv <br /> M (Plot plan, showing size of lot, location of. system in relation to wells,.buildings, etc: must be placed on reverse side.11.,1 <br /> NEW INSTALLATION: (No septictank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size_.................. •••--•- ------ Liquid Depth ................ .. � <br /> . <br /> Capacity ....... Type .................... Material---------­----------- No. Compartments ............ ......... <br /> Distance to nearest: Well <br /> .......................Foundation ---------------------- Prop. Line ....----.............. <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line.........................••: Total Length . (� <br /> 'D' Box ------------ Type Filter Material ...........Depth Filter Material ___........... .......... ... <br /> Distance to nearestWell ..... .................. Foundation ............. ... .. Property Line ......_.._....... .....A. C. <br /> SEEPAGE PIT E ] Depth Diameter ......... .....: Number _............................ Rock Filled Yes ❑ No C <br /> Water Table. Depth -----•--•- ................. ----•--•-- ........Rock Size ........:....................... <br /> Distance to nearest: Weil .....__...._Foundation .................... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..................... Date ........-•--•--.....--.-----••-•-•) <br /> Septic Tank (Specify <br /> Requirements) - s--------............ .a...-..--•-----...----. .....r.. <br /> .------......--••-•----•. ........ ---•h--•--... .....•--•--•-----•----•.... <br /> ? . <br /> Disposal Fiel (specify RequirmI---------- - ------- •... --- <br /> ................ . <br /> i+ <br /> ] <br /> ....................................................... __ - <br /> f[ .(Dr.._a_-w. existing_ and required addition on reverse si e <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. Homo owner or licen- <br /> sed agents signature certifies the following: <br /> t "l certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> f as to become subject to Workman's Compensation laws of California." t <br /> 9 .-•---•••.......................... Owner <br /> Signed .. .. �} `,�c <br /> I � �C�. \ ---.... Title ._...�`- ..a .._._.._ <br /> By ..... ..........••------ .... . .....__.. .-a�------•---....- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-.-----_---. -------• - -• DATE ........ _ .... •-�S�--- <br /> ...:__DATE ....-----.............. <br /> BUILDING PERMIT ISSUED ..........:........ _............_...... <br /> ADDITIONALCOMMENTS ................................. ..........................M---------- . ................................ ---...._---------•-•--- .......................... <br /> ................••---._..........-------• ------------•--•-------------...••------------_--------.:. <br /> ........................................................ .......--.....----••----••---...----..........__........- "_ .......'Date .-. a�J-r- --- <br /> Final Inspection by. .__.........I............ <br /> SAN JOAQUIN LOCAL„HEALTH DISTRICT _ w <br /> r- u 13 24 1_-An c,_. rAA 7/72 3 X <br />