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u FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> j! {Complete in Triplicate? Permit No. ..77._ <br /> .... ................ ................................I�. Date Issued ..-�. .'7y.. <br /> ....................... ..................... ....... This Permit Expires 1 Year From Date Issued <br /> li <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 5..= .... r. -gr _Ae <br /> -..`SLI.• -- "f' ...'• ` <br /> �� CENSUS TRACT .. <br /> Owner's Name ........ is3_ 4 i?.;'�l.� d_�k` ....... . Phone <br /> Address � l t ) <br /> ........ .•----- <br /> Contractor's Name d� � ---..,................. • .�.... <br /> ��` .' i�4a e;v. _..license ". ' <br /> ...... ..............�-•------------.....�.�'�: ... ��.._:.._._ # ...-•--�-- ��-!ij.'. - Phone :-'�s`::�.c'..... <br /> Installation will serve: Residence oApartment Vouse Commercial oTraller Court 0 <br /> Motel ❑Other ..... : " <br /> Number of living units:--------,.-- Number of bedrooms .: Garbage Grinder ------------ Lot Size .. - =+... <br /> Water Supply: Public System stem and name .......:....... . ...Private I` <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay loam 0 <br /> i Hardpan❑ Adobe (] Fill Material .... If yes,type ............................ <br /> (Piot plan, showing size of lot, location ofsystem 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,) O <br /> PACKAGE TREATMENT <br /> .. :SEPTIC TAMC .....................--- .... Liquid Depth .. .....z......• % <br /> 0 <br /> city .1 ,� �_ Type •_ _. s Material.. '!�: No. Compartments ...s&.............. t <br /> Distance to nearest. Well ....c,Fa... ......................Foundation ....L .............. Prop. Line <br /> .......... <br /> LEACHING LINE f No. of lines ..__._ ------------- Length of each line---- `._.._......_. Total Length ..P_3�;: ....... 6 <br /> 'D' Box ..-- ...... Type Filter Material ..At, Depth Filter Material .. ........... <br /> Distance to nearest: Well ....l.lc?_�..:....... Foundation _. -------------- Property Line <br /> -------------•--- <br /> SEEPAGE PITLA <br /> Dept --- Diameter . . Number ._... ................. Rock Filled Yes,�J No <br /> �,. <br /> Water Table Depth . ?--•--•--._ .............. <br /> Distance to nearest: Well ! -_- - ...•..,,,••__—Foundation ... Prop. Line .... . - <br /> REPAIR/ADDITION Prev. Sanitation Permit!# --_-.--- Date <br /> Septic Tank (Specify Requirements) ............................................................. <br /> I <br /> Disposal Field S ecif-- Re_I uirements) ................................................................ •� - ` - - <br /> ------ --- <br /> ---- - R <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, Slate Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licew <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 /> By ..-- ................ ----�..... .... ....�?tz�'K.... __.....__......-•-------------.. Title ----- .`��'%.�'---,......---......_._._......_.............._....... <br /> (If other than owner) U <br /> II FOR DEPARTMENT USE ONLY -' <br /> APPLIBUILDING PERMIT ISSUED _ <br /> CATION ACCEPTED BY.: ------------------------- DATE ` <br /> ,. .:..............DATE <br /> ADDITIONAL COMMENTS _._... '............... <br /> : , <br /> -n : = -: :-:::......................................: ......::---- ......................................__._..... <br /> - ► <br /> FinalInspection b ••-•------•-----------------------•----------•-•----------------- <br /> p Y ........................I......... Date ... .. <br /> ............-----------•........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y C <br /> E. H.13 24 1-'68.Rev. 5M <br />