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FOR OFFICE USE: <br /> APPLICATION rp FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _7.1---U_5-/ <br /> ------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein F <br /> described. This application is made:in compliance with County Ordinance No. 549 and existirw Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ _ '___ ._fa _ k' __ _ /,tmwXENSUS TRACT __________________________ <br /> Owner's Name `_Ij 1��-e-----pw *7?—s4 - = ------------�------Phone c.,-_` /_� ------- <br /> Address _.�..4-------j.&1--`-47----/---?190----434. 7---------;------------------------- City 6sJ /t✓ f'1 '------------- -- -- --- <br /> Contractor's Name .-1. 1. 1'%_.--- l -/I-�'1x-�e�--- --------------------------License # ± - Phone��f _. <br /> Installation will serve: Residence [4 Apartment'House-[:] Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other ----'------------------------------------- <br /> Number of living units:------- 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'[A Silt❑ ! Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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'avoilable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ize---------------------------------- ------ Liquid Depth ---------------------.----- <br /> Capacity --- ---------------- Type ------=-- --------- Material--------------- ------ No, Compartments ---------------.-•---- <br /> Distance to nearest. Well _.______ _______________________Foundati n ______-____________ Prop. Line ---------------------- <br /> LEACHING <br /> _---__- _-__---__ <br /> LEACHING LINE [ ] No, of Lines ________________________ Le gth of each line------------ --------------- Total Length ____-_____-.____-__-----_-__ <br /> D' Box __.--------- Type Filter M erial ____________________Depth filter Material --------------------._______________.__.____ <br /> Distance to Inearest: Well _____ ______________ Foundation _._ ____.________.__ Property Line ________________________ <br /> SEEPAGE PIT [ ) Depth ____________________ Diamete _:______________ Number _____ _____-_____________ Rock Filled Yes ❑ No I] <br /> Water Table Depth -------------- ------'------•--------------------Ro k ize -------------------------------- <br /> Distance to nearest: Well ----------------------------Fou d i n -------------------- Prop. Line--------- ------------ <br /> it <br /> (Prev. Sanitation Permit# __________ ________ ______ ______________ Dat ________________._________________) <br /> SepticTank (Specify Requirements) ------------------------------ ----------------------------------------------------------------------------..__,,.--------------------------- <br /> Disposal Field (Specify Requirements) ----------------_--- ------------------------ --- ---------------------- ------------------------------- <br /> -C Z----------- <br /> P <br /> ---------------- ------------ <br /> P ; --------A9-�--- �W-- <"/--=,�1'W_<----------------------------------------------------- <br /> --- -------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that l 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, 1 shall not employ any person in such manner <br /> as to become sub)ect4 Workman's Compensation laws of California." <br /> Si ne ----------------I ----- Owner <br /> By ---------------------------------------- ------------------------------------------ Title -------- --------------------------------- --- --- ------------------- <br /> (If <br /> ------- ----------(If other than owner) <br /> FOjREPAATMENT USE ONLY <br /> APPLICATION ACCEPTED BYf --------;------------------------------------------------------- DATE }�lr <br /> BUILDING PERMIT ISSUED ---------------------- -------- ------------------------------------------ --------------DAT(: <br /> ADDITIONALCOMMENTS -------------------------------------------------=--------------------------------------------------------------------------------- ----------------------- <br /> ------------------------------------------------ - - ----------------------- ------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------ <br /> ------------- -------------- ------------ <br /> Final Inspection by: __.-__ , <br /> �y= y <br /> AN AQUIN 'LOCAL HEALTH DISTRICT Date <br /> E. H. 9 1-'68 Rev. 5M <br />