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f <br /> FOR OFFICE USE: ' T"-�a <br /> APPLICATION FOR SANITATION PERMIT <br /> -- Permit No: <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ----------- -------------------------------------------- <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 Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -----�0 �------I �'" -- --- AM-—X4100----------------- - --------CENSUS TRACT S49 <br /> SF <br /> - ! ° <br /> , <br /> Phone Name -- - ------ ------------------i------------ ------ ----- ------------------------ <br /> N CityN" --------------------- <br /> Address <br /> --------- 0 4LA7------ Lk- <br /> ContrContractor's <br /> actor's Name -----SeA-------- ----- ------------------------------- -------------------------License # ------- ------ Phone ------- ---------------------- <br /> Installation will serve: ResidencekApartment House❑ Commercial ;❑Trailer Court l❑ <br /> Motel ❑ Other -------------------------------------------- <br /> o5... _ <br /> Number of living units:__ ___- Number {off bedrooms __yy------Garbage GrinderV0Q__... Lot Size 1b0__ 5--__- -_____..--- <br /> Water Supply: Public System and name .TrNv>Gj"[�. `---------.--------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet.' Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam •❑ Clay Loam j] <br /> Hardpan ❑ Adobe:�< Fill Material ------ If yes, type ---------------------------- <br /> (plot <br /> __________________________(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> Q <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 -------------------------- Ilk' <br /> _Capacity ------------.------- Type -------------------- Material---------------------. No. Compartments - --- ---------------- <br /> Distance to nearest: Well ___________________________________Foundation --------------- ------ Prop. Line ____________________-. <br /> LEACHING LINE I: ] No. of Lines ---------------- ------ Length of each line---------------------.------ Total Length _-_______._________.._.__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------•. <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ----____-.____.__.:____ <br /> L, <br /> SEEPAGE PIT [ j Depth ---,.--------------____ Diameter ________________ Number ---------------------------- Rock Filled Yes 0 No 0 <br /> WaterTable.,Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest; Well ---------------- ------------------ -=__Foundation -------------------- Prop. Line --------_------------ <br /> REPAIR/ADDITION(Prev. Sanitation iPermit# -------------------------------------------- Date ________.__-_-__________--.-------) <br /> SepticTank (Specify Requirements) ----------- ------------------------------------------------------------------------------------------------ --------------------------- <br /> Disposal Field (Specify Requirements) � )»1+--- -- ----Qtr--- --- ��` • ? _1T)N ------------- <br /> -------- eqT%q_ --rat, 5-------I-_---- =' = '-----------------------------------'------------------------------------------------------------------------------------ <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 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, I shall not employ any person in such manner <br /> as to become subject to Workman's C pe ati.on laws of California." <br /> Signed '� rZ --------.---,---------------- <br /> Owner <br /> ------------------------------------------------------ ---- ----------------------- Title . ----- ---------- <br /> fif other than owner) <br /> E FOR DEPARTMENT USE ONLY Q <br /> APPLICATION ACCEPTED BY _. .�w..-- ------------------------------------------------- -- --------------- DATE a C1 9t- ----------------- <br /> BUILDING PERMIT ISSUED ---= --------------------------= DATE <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- ---------------------------------------------------------- ------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --Or------------------------------------------------------------------------------------------------------------------ -------��- <br /> --- --------------------- ---- <br /> ------------------------------------------------------------------------ <br /> --------------- -- --- -- <br /> Final Inspection by ----- - -- - - - - - -- -- - -- Date <br /> SAN JOAQUIiv LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />