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f OR OFFICE USE: <br /> APPLICATION 'FOR SANITATION PERMIT permit No: <br /> -------- ------------------------------------------IN--- (Complete in Triplicate) <br /> -------------------------------------- <br /> --- ---------- `` Date Issued �__---'7--.. <br /> This Permit Expires 1 Year From Date 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 applicatiori'�is made in c'mpliance with unty Ordinance No. 549 and existing Rules and Regulations: <br /> -- -------------CENSUS TRACT -------- ----•-•---- <br /> JOB ADDRESS/LO T10N r--l?-- l <br /> Owner's Name ". ' - --- -----f <br /> �� I -------Phone ----- -------- m, <br /> N' <br /> Address --------4(-, -- -------- ---- ------------------..--. City -- --- -- <br /> Contractor's Name 0M - 'License # -_` Phone ^" <br /> v <br /> -- ----- ---- <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other _ -------------=" <br /> #� Number of livin units:-__.�I______ Number.M of bedrooms -_-___-_.___Garbage Grinder ------------ Lot Size - <br /> 9 E <br /> Private <br /> eat Sand Loam ----------------------- <br /> Water Supply: Public System and name;___----___ <br /> -------------- <br /> Character of soil to a depth` of 3 feet: Sand❑ Silt❑ Clay ❑ P ❑ y Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location <br /> of system in relation to wells, buildings, etc. must be placed on reverse side.] <br /> NEW INSTALLATION: {No septic tank'for seepage pit permitted if public sewer 9s available within 200 feet,) <br /> i <br /> _ Liquid Depth -------------------------• <br /> PACKAGE TREATMENT { ,] SEPTIC TANK,[ j Size___------------------ ------------- -- .2s <br /> C�I -------------------- <br /> -a acitY ---- --=I ----- - TYpe -------------------- atera ------------- -------- . Compartments �! <br /> ' <br /> Foundation --------------------- p• <br /> Distance to nearesfi: Wel! __________ -- Pro Line ...............;_. � <br /> ` -------------------- - <br /> LEACHING LINE: [ j� N�. of Lines __Ip-.. ------ Length of each line------ -- --------- ------ Total Length ---------.-.-----------_-- <br /> D' E30x _ ._ _,� Type�Filter Material ---------------------Depth Filter Material --------------------------------------------- <br /> ----------- <br /> ------- <br /> --- -------------------------•--- - -----•- <br /> � ------------------------ <br /> I ' <br /> Distance'to nearest:l7Vel1"`" _ `"" *Faun a ____:__ . Property Line. <br /> �N Diamete Number _.----- ----------------- Rock Filled Yes ❑ No 0 <br /> SEEPAGE PIT [ ] Dp pth ------- ----- = f <br /> r �M iI : <br /> ' ater Table Depth - ------------ <br /> '..Foundation <br /> --------- f: Rock Size = <br /> � ► it IM �---------------------- <br /> a <br /> Distance to nearest: Well -------------------------- _ .Foundation _______-____._ -"-= Prop. Line ------------ ....... <br /> => - <br /> 'I 'M r r_. 7 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----"`----------------------------------- Date -------------------------------- ) <br /> - - ----- --------•-•-- <br /> Septic Tank (Specify Requirements) ....------ ----------- ----------- O <br /> IM. ` - --- - <br /> Dis os field [ pecify Requi amen#Is) J -- - '--.,�`�- = `' � <br /> K. <br /> ------- -- - <br /> i -! ----- ----------------------------- ----------- '---------- --------------------------------±--------------=-------------------------- <br /> ----------- --------------- <br /> Y r (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 /> F "I certify thdt-in�theperformance of h.t work for which this permit is issued, I shall not employ any person in such manner <br /> v <br /> as to become subject to Wo an's Compensati ws of-California.':;. <br /> — <br /> ,f �- <br /> Signed --------- ---- -- -_ --------:---- - ' ------ Owne ter► <br /> '-_ <br /> ----- <br /> t(� � title -. f <br /> (If other------------------------ <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> I � �— <br /> APPLICATION ACCEPTED, BY _.-- '= �h - ----------- ------ DATE ---- --------- <br /> BUILDING PERMIT ISSUED -- ------ ---- - �-�=3`' DA E ---- �! <br /> c�- -------------------------- <br /> ADDITIONAL COMMENTS -------------- <br /> ----------:-"_.. lit:--- -0--------' - = <br /> -- ----------- <br /> - ---------------------- <br /> -- ------------------- <br /> l � -- 3 <br /> -------- - <br /> - <br /> ---- -- ----- ------------ <br /> Date <br /> Final.Inspection by 2- --- ------ -------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H, 9 1.'68 Rev. 5M <br />