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FOR"OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. _-- ---1:---71..L... <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued---------------------------- <br /> T_-3-0-----7 <br /> - <br /> «-7 3&- o- '03 <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 cpmplionce with Counm Ordinance No. 549 and existing Rules and Regulations: <br /> 2 7,7 3 qr • F-t r 6-uO <br /> JOB ADDRESS/LOCAT * C SUS TRACT -------------------------- <br /> Owner's Nab---4v- - - -- --------- ---- -- -- - - ----------------------------------------------------------- -------Phone ---------------------------------•-- <br /> Address _- City <br /> -------------------------------------------- <br /> Contractor's Name _ -_-_A ? License #.f`s ? Phone <br /> _ _ . <br /> Installation will serve: Resi ce ❑ Ap ent House-E] Commercial'❑Trailer Court ;❑ <br /> Motel ❑ Other ----------------------------------- -------- <br /> Number of living units_____________ Number of bedrooms __ -----Garbage Grinder - Lot Size -------------------------------------------- <br /> Water <br /> _-___--_----_-------.---.- .---_-_-__Water Supply: Public System and name _----ty ---------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand''Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ `� <br /> Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ---------------------------- vo <br /> Xt <br /> (Plot plan, showing size of 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 [ I SEPTIC TANK[ ] Size-------1-;� cf-79--------------------- Liquid Depth _----__-__-_--_- <br /> Capacityl,-1 C --- Type -------------------- Material----_------------------------- No. Compartments ---_----_-_-_-__------ <br /> Distance to nearqa Well ------------------------------------Foundation ---------------------- Prop. Line ------------------ _ <br /> LEACHING LINE [ ] No. of Lines ---- ----------- Length of each line-------ly-Q-----.--_--- Total Length <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.-------------------- <br /> Distance <br /> ._-----_ _ .-- <br /> 1 --- Foundation t Property Distance #o nearest: Well _--,��7-_--_-__- -/C2-------------- -- Pro a Line _______._._.. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth -------- ---'/_ - -------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------------- ----------.-Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- --•---------------------------- <br /> DisposalField {Specify Requirements) ------------------------------------------------------------------------------------- ----------------------------------------------- <br /> ------------------------------------------- - ---------------- --- <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 done9n accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local-F .0 th District. Home owner or licen- <br /> sed agents signature certifies the following: ' <br /> "I certify that in the performance of the work for hich this permit is issued, 1 shall not a h7 any person in such manner <br /> as to become subject to Workman's`• ompi sationlaws of California." \ <br /> Signed -- -------- -------------- --- ---- #-------- ^--------- Owner <br /> Title----- --------------- w - ------------ ------- - ------------- ------------ <br /> (If other the <br /> FOR PAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ------ -- <br /> --- ----- ------------ ------------------------------------------------- DATE ----F3d•---- -------------------- <br /> BUILDING PERMIT ISSUED --- - �- -----DATE --------k--------------------------------- <br /> ------------------- <br /> ADDITIONALCOMMENTS - -------- ------------------------------------------------------------ ------------------ <br /> ---------------------------------------- = ------------------ ------ , --------------------------------------------------------------------- <br /> -- -: <br /> ----------------------------------------------- <br /> -- ----------------------------------------- --------- ---- <br /> ------------------------------------ ------------------------------------------------------------ - ----- - <br /> a ; <br /> Final Inspection by: ------------------------------------------------------------- ----------------------------- Date ` ----------- ----------------- <br /> - <br /> J0AQWII`+,1:LOCA.. HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M 36 <br />