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At" <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> 0 <br /> Permit No. -.77- ---:`-3/ <br /> (Complete in Triplicate) <br /> _____________________ This Permit Expires i Year From Date Issued bate Issued T- -----3 . <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 .9'1L)-fl------- ----------------------------------------------------CENSUS TRACT ------------------- --•--- <br /> Owner's Name ---------------------/_�19/lIVAL-----� Arl--------------------------- -------Phone ------------------ <br /> Address o��a�Q _ 5;917. f1, f�2�C?. Cit '� �' <br /> Y f-------------------------------------------------------- <br /> Contractor's Name -------------------- - 4VAlAL-----------------------------------------------.License # --------------- -------- Phone <br /> Installation will serve: Residence [T Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------4_ Number of bedrooms __._.....Garbage Grinder _________ Lot Size _ &K-CIM-0------------------ <br /> Water Supply: Public System and name --------- ---- ------•---------•- ------------------------------ ---------- ---------------------------------Private E�9— <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill Material ____________ If yes, type ____________________________ <br /> (Piot 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 e- Size----------- K?------------------------- Liquid Depth ____y ______.__---___ <br /> Capacity - 19 _-- Type , - -if----- Material ___-- No, Compartments -----` ............. <br /> Distance to nearest: Well ______ FJ_C?____________--------Foundation ___/C?____________ Prop. Line ---_��__P.......... <br /> LEACHING LINE [ ] N A s ---a©_ --- - e---------------------------- Total Length -----------_----........_... <br /> 'D' Box .%-I------ Type Filter Material �i'RO _____Depth �Fiilter Material ___'7___ _______________________ _______ <br /> Distance to nearest: Well ___/�[9 __________ Foundation ----aq ______.____ Property 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 /> Disposal Field (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 become ct to Wo man's�Co�mpensation laws of California." <br /> Signed)' ��r.r "'t ------------------------------------ <br /> Owner <br /> By -- --- ----------------------------------------------- ---- ------------------------- ----------------- Title - - --------- <br /> (If other than owner) <br /> FOR DEPAXTAkEJNT U5 ON Y <br /> APPLICATION ACCEPTEDR'V ---- ----------------------- ----------- ---- ---- ---- --- - ------- DATE _. - � -�Y ------------------- <br /> BUILDING PERMIT (SSU D ----------DATE -------------•----------------- -------- - <br /> ----------- ------------------- --------------- <br /> ADDITIONALCOMMENTS ----- -- ---------------------------------------------------------------- --------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ --d� ------------ - - <br /> Final Inspection by: ------------------------------------------------------------------------------------- V�- -------- Date l <br /> SAN JOAQUIN LOC40HEALT (STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />