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FOR OFFICE USE: <br /> �APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <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 - <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -------4 C--------Lo=-- 9' 7__V---,------------------------------- --------------CENSUS TRACT -------------------------- <br /> Owner's Name R ` 'IQ jUt4° --------- ----- - �s <br /> Phone - - L� --- <br /> Address ------------------I ------------------`-------------------------------------------- --• City - C'`------------------------------------ <br /> ------------------- <br /> Contractor's Name ------------ ----- _W__�--------=---------------------------------=-------License # ------------------------ Phone -------- <br /> Installation will serve: Residence M Apartment Housef] Commercial❑Trailer Court i❑ <br /> Motel ❑Other <br /> - ii i <br /> Number of living units:_________ Number of bedrooms ---/______-Garbage Grinder __------ Lot Size ------V___Q`___A----------------------- i <br /> { <br /> Water Supply: Public System and name __T7iACi5f---�4___V Z -------------------------------------------- ----------private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[-] Silt❑ Clay ❑ Peat❑ Sandy Loomf] Clay Loam ❑ , <br /> Hardpan ❑ Adobe Fill Material __/u_ 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 available within 200 feet,l <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --------_----------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line _____.______.__......_ Q <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ._________.___________._... <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------_.--.---------. ----.-.---- � <br /> Distance to nearest: Wel! -----------------------—Foundation � ---'" Property Line ` <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------. Rock Filled Yes ❑ No (3 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line .--------------.------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----- -------------ii----------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) ---------/,90,0 2�!___ 1J ___ ___ /p.c.e-,-- <br /> Disposal Field (Specify Requirements) 1 �� � �-------------------------------------- <br /> -------------------------------------------------------- ----------------------------•-------------------------------------------------------------------------------------------------------------------- <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: I <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 d <br /> as to become subject <br /> -�to�Wti <br /> yorkman's Compensaon laws of California." <br /> Signed'`L. _��#_ - __1-Y_\ +.�- {--- Owner <br /> By ---------------- ------------------------------------ <br /> ----------------------- <br /> -------------------------- - ------------------------ _ Title <br /> --------------- <br /> (If other than owner} <br /> FOR ARTMENT USE ONLY ] <br /> APPLICATION ACCEPTED ----- -,-- --- ----------------------------------------------- ----------------- DATE --- ��- ��--------------- <br /> BUILDINGPERMIT ISSU ---------------------------------------------------------------DATE ------------------------------------------- <br /> ADD1TlONAL COMMEN - --- - - ------- -dN <br /> ------------------------------------------------------------- <br /> --------------- --------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- ----------------------------- --------------------------`•------------------------------------------------------------------------------------------------- <br /> ------------------------------- - -- - /(-- ------------------- <br /> Final Inspection : _____ _ -------------- <br /> Date = ;« C�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -- ------------ --- -E. H. 9 1-'68 Rev. 5M <br />