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FOR OFCl= Slr APPLICATION FOR SANITATION PERMIT <br /> -------------------------- ----------- ---- <br /> (Complete in Triplicate) Permit No. <br /> ------------------_.------.----------_------------------- This Permit Expires 1 Year From bate Issued <br /> Date Issued S 1,?�__7/ <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 Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..__.. 'kFRjrChjl(___Ave.-3---Stoc-ktouj-_.Cali.f-.__CENSUS TRACT ................ ........ <br /> Owner's Name -----------------------Ji.m.-T-anaka ------------- -- ------ Phone - <br /> 52'+_Fairchilsi__Tid.-t S.tackt�ariy�---Calif ----- <br /> Address -------------------------- <br /> -Contractor's Name ----------D_ouglaS---Septic---Tank---------------------------License # ----25. ,2-7-f---- Phone _537-74-0-2-------- <br /> Installation will serve: Residence [�Apartment House ❑ Commercial ❑Trailer Court ;❑ <br /> ti <br /> Motel ❑ Other - ---- -----------------------•-------•- <br /> Number of living units:---1.------ Number of bedrooms __________Garbage Grinder __- -- Lot Size ... <br /> l <br /> Water Supply: Public System and,name .--------------------------------------------------------------- ------------------------------------------ Private.�R , <br /> Character of soil to a depth of 3 feet: Sandi] Silt❑ I-flay ❑ feat❑•" Sandy Loam -❑ Clay Loath ❑ <br /> Hardpan ❑ Adobe E] Fill MatOial ------------ if yes, type ----------------------------- <br /> t <br /> t (Plot plan, showing size of tot, location of system' in relation to.welts.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 /> k PACKAGE TREATMENT { ] SEPTIC TANK [*] Size--5XI_0X_r-5------------_-------_---- liquid Depth __-1_20G__Ga],, D <br /> I Capacity ---1-200---galypePre!-_CaStMaterial-_Come-ete No. Compartments. ....... ........:.... <br /> -S/#- <br /> Well, ,_ _.,,:�O----------------------Foundation _fc]--------------- Prop. Line ---------------------- <br /> .- F <br /> LEACHING LINE � [,� Na. of Lines � g � g <br /> Distance to nearest: W- -'"""Len Length each I' e._._ 0----- Total Length ------------ <br /> 'D' Box -- _ - 4Ty,pe,"J ilter�Material= _--- -_4 r4-----Depth Filter Material -13--------------------------------- <br /> Distance to nearest: Well ------ff,6 -------- Foundation _1P---------------- Property Line _.- ------------------- <br /> [ ] p �`~' Rock Filled Yes ❑ No i❑ <br /> SEEPAGE PITDe th ---_---_-.`: __ Diameter,4:�-._______-_-__ Number ----- <br /> WatDistance to nearest: Well -------------------- <br /> = IJ <br /> = Rock Size <br /> er Table Depth ---------= "---------------------- <br /> ----- Foundation -------------------- Prop. Line ------------- ---- --- <br /> k;� REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ___ _____ _______ Date ---------------------------- i <br /> i ¢ <br /> Septic Tank (Specify Requirements) _ _ <br /> M <br /> F <br /> ------_----- ------------ <br /> Disposal <br /> ___________Dis osal Field (Specify Requirements) - • - --- --' <br /> ------------------------------­------------------ ------------ <br /> i ___________________ <br /> i ------------- -- --------------- ----------- ------------------------------ -------------I-- ---------------- ---------------- <br /> (Draw existing and required addition on reverse side) <br /> F 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 Compensation laws of California." % <br /> Signed _ :_-�- -----------�----- Owner - <br /> - -- --- ------- - ----- ----- <br /> ofother than owner)---- - - -------�----- - -`--� <br /> BY ---- - �------- ---------------- Title ..---•-- -- - --------------------------------------------- <br /> F <br /> - - -.._-- -- -------- --- <br /> weer) - - - - - �, <br /> F PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t.., - -------------------------- <br /> ------ DATE - ---------• <br /> BUILDING PERMIT ISSUED ------ -- __-- _ - -- ----- ------------ ---------------------- ----------------------- <br /> DATE ------------------------ ------------------ <br /> - <br /> ADDITIONALCOMMENTS = --- --- -------- ----------- ------------------- ----------------------------------------------------------------------------------------- <br /> ------------------- --------------- <br /> ------------------------------ ------ <br /> - ---------------------------------------------------------------------------------------------------------------------------- <br /> - <br /> ------------------------------------------- - ---- -- --------- -- - ----------------------------------- -- ------ ----- ---- -- - - ----- -- --- ---------------=-------- - <br /> i Final Inspection by: -------------------------------------------- ------------------------Date _ ------ <br /> AN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />