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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 1st <br /> (Complete in Triplicate) Permit No. ... ....... <br /> - Date Issued .. ./.:�;ff�':%.` • <br /> ............................... This Permit Expirei 1 Year From Date Issued <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 ........... -...CENSUS TRAC`f ...................... <br /> Owner's Name ................ . _........ ---.---Phone <br /> Address ................. ---.. --------- ------------ Cit 1"-....-- <br /> Contractor's Name -- ------ ------ -----------------------License # 07,`S.S -. -• Phone .dam �Sd k <br /> Installation will serve: Residence MApartment House❑ Commercial ❑Trailer Court ;❑ <br /> MotelOther ... ...... <br /> Number of living unts:....1........ Number of adrooms ,�_Garbage Grinder ._.__. _lot_Size_'. - tt --- G----••••-•.-.•- <br /> Water Supply: Public'System and name --- - --------------------------•- ... ---------------------------------------------------------Private ; <br /> Character of soil to a 'depth of 3 feet: Sand]] Silt❑ Clay ❑ Peat❑ Sandy Loam CK C ay.Loam <br /> Hardpan ❑ Adobeh❑ Fill Material ............ If yes, type ......... .........•-------- <br /> {Plot plan, showing lize of lot, ,location of system in..relation}to wells, buildings, etc. must be p ' <br /> aced on reverse side.) <br /> NEW INSTALLATION:I (No septictank or seepage pit permitted if public sewer is available within 200 feet,) _ <br /> PACKAGE TREATMENT [ ] SEP11C TANK I ] Size----..........................................:. liquid Depth .......................... <br /> 44 Capacity .. ._ . . Type ....... --...... Material... ................. No. Compartments ............ <br /> i <br /> Distance to nearest: Well . ..-_..----... _----------------Foundation ........__.- . ..- Prop, Line ..-------............. 4 i <br /> LEACHING LINE [ ] No. of Lines - ... _. - -- Length of each line ......... ....:, Total Length ------------------ ....... . 4 <br /> 'D' Box _.,.. . _ . Type Filter Material -_-----------------Depth Filter Material .................--..........-•--•........... { <br /> Distance to nearest: Well ........................ Foundation .-.-.-..._._...._....-- Property Line ..------------------_- <br /> SEEPAGE <br /> --.-SEEPAGE PIT ( ] Depth . . . ... ......... Diameter ................ Number .................. Rock Filled Yes ❑ No I[� <br /> Water Table Depth ................................................Rock Size ...........................1-.:. <br /> Distance to nearest: Well ..........Foundation ._......... ....... Prop. Line .............. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# :.......:..... Date ___._...__-. --.-_--) <br /> Septic Tank (Specify Requirements) ..:...._.. 1 -O._ : L...._. r 'v! .-... ............. ......................' <br /> Disposal Field (Specify Requirements] ....,. " - h/l. G..-.-------_....... .......... <br /> `� �. ............------..... ------------- ---..... !. -.... ----- <br /> .0 , <br /> t <br /> (Drew exisi�ing and required addition on reverse side] <br /> I hereby certify that I have prepared this application andAhof the work will be done lin accordInce with San Joaquin <br /> County Ordinances, State Laws, and Rules and(ie.gulatioris,ofthe,Son Joaquin local Health District. Horne owner or licen- <br /> sed agents signature certifies he-following:., y <br /> I t `.q� -.- I I a V- . <br /> "I certify that in the performan'ie of•the work-forlwhich-this permit is issued, I shall not employ any person in such manner <br /> as to become subject I Wiorkman's__&�mpe6sation fdwi--of California." <br /> d <br /> Signe :_.. . Owner <br /> BY ........ ------------ -------- ................. ....__... .. ,Title . .... .... ......... ........ i . .............. <br /> jlf Ether )hori owner) <br /> FOR DEPARTMENT USE ONLY — <br /> ACCEPTED <br /> BY __ <br /> ------- ---------- --- -- - DATE . ... .... y..._.. <br /> APPLICATION <br /> BUILDING PERMIT ISSUED .---...._.._..----- -------- ---- -------------- - ------ --- ......=._�; ------------..DATE __.._................_.. ._.......:_. <br /> ADDITIONAL COMMENTS ........._--------......................--....-. ......-------- ".. -----._..- ! '�--.... -- <br /> ................................ _..•-.............. ............. --- . <br /> ---------------------------------------------------........................... ........................................ --.....-------------------.-....... <br /> ------------------_- - ----•- - <br /> FinalInspection by: ........ ----- . `... .... --------------------------------------- ---- ------ Date .................. ----- ........ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c"W' Z3 24 ,_ co aa„ 'PAA 7/72 3 j4 <br />