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i=(3R OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----------------=------------------- <br /> --- _ ' Permit No,. --�Z--�-�--- <br /> (Complete in Triplicate) <br /> ----------------------------------------------------------- <br /> ________________________ ____ ________________--________ This Permit Expires I Year From Date Issued <br /> Date Issued -- -J_2 <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 gompl.iance:w.ith..County Ordinance No. 549 and existing Ru es and Regulations: <br /> JOB ADDRESS/LOCATION1 ___ �-G�___ __--CENSUS TRACT <br /> Owner's Name _.-_ _ �-= _ :,�,�� <br /> ----------------------------------------------------------- -----.-Phone .- --------- <br /> Addre <br /> _ _ <br /> ss �� � -���-----�-f�--"-/ ��------------ -- ------------ City -- ----------�--���---•--•---.._..--- <br /> , r, <br /> Contractor's Name --------- <br /> q <br /> � ------------------------- ---------License #,2L_/_r-��Phone <br /> Installation will serve: Residence ❑ Apartment.Hous -❑ Commercial ❑Trailer Court <br /> Motel ❑Other __� `a ! © f�f? 7 S� <br /> Number of living units_____________ Number of bedrooms ------------Garbs e; Grinder ------------ Lot Size . <br /> 1 <br /> Water Supply: Public System and .name --------------------------------- •-------------------------------------------------------------------------•-Private <br /> I ITS <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat)< Sandy Loam ❑ Clay Loom .[] <br /> Hardpan ❑ Adm�e . Fill Material ------------ If yes,type ______________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �I <br /> NEW INSTALLATION: (No septic`tank or seepagefpit permitted if public sewerris available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------- -r--- F--.------- Liquid Depth ---A-------------------- <br /> f. f r <br /> Capacity _ - Type ..--- - Material_______________ _ No. Compartments ) <br /> Distance 10 nearest. Well r ' <br /> Prop.-,.Line <br /> ' - <br /> - - ----- ------- <br /> Foundation - --------- ------- Pro Line --------------.... O I <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of'�eacf7line�"" -- ._ -__ Tot' -Length [ <br /> 'D' Box --.-i Type Filter Material y . --------- pth Fil= r Mterp_ <br /> �� <br /> ouoroper Distance to nearest: Well ______________________ Fndatn Line t_ -- <br /> -- <br /> - ------ - <br /> s * <br /> SEEPAGE PIT [ j Depth ---- --- _______ Diameter ---------------- Number --------------I-._--- __--- Rock` Filled Yes t[] No C] <br /> Water Table Depth ------------------------------------- ---------Rock Size ------- #- -'- <br /> Distance t inearest: Well -------------------_---------?---------Foundati6A ..... _,—_-e.--JProp. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---- ----------I--- <br /> `” <br /> Septic Tank (Specify Requirements) - --------------------- ---= - ----- ---------------------- - ------ --------- ------- <br /> Disposal Field (Specify Requirements) - ---- / 1-_ ___�___ --, /" d,e! --, -------------- <br /> . - ----------------------------------------------------------------------------------- <br /> isting-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 artdl Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certifythat <br /> 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 Workman'" oC m'pen aficn laws of"California." <br /> Signed -------------------- - - may._------- ( - --- - =--------- Owner <br /> BYr --- ------ - - - --- ----------------------------------- Title ------------ <br /> (If er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -' --'-----------_- _._ . DATE __- .!z 7 Z- <br /> ----- ---------------- -------------- --------------------- <br /> BUILDING PERMIT ISSUED - i---------- ------- -------- DATE <br /> ----------- <br /> ADDITIONALCOMMENTS ----------- ----- ------------------ ----------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ­VNmy <br /> - - - - - - -----------------r--=--- ----- ----- - - - <br /> Fina! Inspection by: _. � �- Date ' f� 7 <br /> ------------------------r --- ----- <br /> SAN JOAQUIN `LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M " 4 I <br />