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FOR OFFICE USE: <br /> APPLICATION FQR,SANITATI4N PERMIT <br /> --------------- ---------------------------------------- <br /> (Complete in Triplicate) Permit No: __.2 '_ .___S <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued -_ <br /> - <br /> - <br /> ---------------------------------------- ----------- <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 application is made in compliance with County Ordinance No. 549 and existing les and Regulations. <br /> JOB ADDRESS/LOCATION -:--._CEN US TRACT -------------------- ----- <br /> Owner's .Name -------------- •-------------------------- ----------- ------Phone -------------------------------- <br /> Address _/_A-10 / - City <br /> '1 <br /> 19- <br /> Contractor's Name -_-- r __ R�___ �. i ,r "------------License # ,+ /7-3_ Phone 4 _ - -' <br /> installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court [] <br /> Motel ❑ Other 4),A-4----------------- <br /> Number of living units:_,4---__ Number of bedrooms ----____Garbage Grinder ------------ Lot Size _ 1 --- --------------- <br /> Water Supply: Public System and name ---------------------------------- ----------------------- ---------- ----------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'X Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe.0 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.) <br /> NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) / 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----' .-X- X---?--------- Liquid Depth -_ __� _-_________-4Z 94 6 <br /> - Capacity .f .___ Type�6_40e_Material__4 7s_ _ o. Compartments ___ .,. ...... <br /> Distance to nearest: Well ____/(9 _____________Foundation 0� ------------ Prop. Line 47.......7------ <br /> c <br /> LEACHING LINE [ ] No. of Lines ---AZ Length a'# each line ---- € Q.___________ Total Length __�4&-----.---- F <br /> /� � � ?( ��j/ .01 <br /> 'D' Box _4 r� Type Filter Materiae- ---------Depth Filter Material ---cool ---______________�_____-_--.-- <br /> l <br /> Distance to nearest: Wel16, <br /> l "--------_ Foundation _______________ Property Line �_.-__-___-_---. f <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ---------------------------------------=--------Rock Size -------------------------------- V11 <br /> Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> G <br /> Septic Tank (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 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 becble t t Workman' ompensation laws of California." <br /> Signed - o e)suP -'' ----------- Owner <br /> BY ----------------------- --------------- --- ---- ------------- -------------- Title -` <br /> (If other than-10-1wned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -11�--- - - -----. DATE ------ -' 7 3---------- <br /> -- --------------- <br /> BUILDINGPERMIT ISSUED ------ - ---------------------------- -- --------------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------- -- -------------------------------- ----- ------------------------------- -----------------=------------------- ------- <br /> ----------- ------------------------ ------- --- ---- ----------- -iJAQUIN <br /> ------------------------------------------------------------------------------------------------------- -- ---- <br /> ---------------------------------------- <br /> --- <br /> -- -------- - }----------------- - -- - ----------------------------------------------------------------- ---------- <br /> 7 ------ <br /> Findl-lnspection by: ------ -- - - - -------------------------------------------------- <br /> --------------Date - - /- - ------ <br /> N LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />