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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT *; <br /> ----=------------------- ----------- Permit No: l- <br /> ' (Complete in Triplicate) _ <br /> Date Issued <br /> This Permit Expires,) Year From Date Issued <br /> ----------- -------- <br /> t 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 .,__ �-a - ------ �� ----------------------------------CENSUS TRACT --- <br /> nnnn 4` <br /> Owner's Name Mr.--�_=� -Se.ta" : -------------------Phone __.�l��SC�'1------------ <br /> Address ..-. ' -,s - ---------------------------- --- _`'CityC>C'10 --------------------------------------------•-•------ <br /> Contractor's-Mame --�e K-.:----------- -------�"------------------------------ ----License # ------ Phone ------ .--------------------- <br /> Installation will serve:-i, c»,� Residence Apartmenfi"House❑ Commercial :❑Trailer Court ',F] <br /> '• Motel Other ''-------- i <br /> F� �`,., ! <br /> Number of.living units:.__._----- Number of <br /> bedrooms ___.__:Garbage Grinder 0--.._ Lot Size -_15D_.x__bS__----______-_ <br /> Water Supply: Public System and name ----L�µF--- .--- ---- =-------------------------------- - Private ❑ <br /> PP y y VLXC ,t of <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Pe6f ] Sandy Loam ❑ Clay Loam ❑ <br /> I i Hardpan ❑ Adobe D< 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 available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size----------------i------------------------------- Liquid Depth --------------------------- <br /> Capacity <br /> " ------,---Capacity -------------------- Type -------------------- Material---------------------- No. Compartments f------•---- <br /> Distance to nearest: Well _-_________________________________Foundation _..------------------- Prop. Line __-__________:__-_-_ <br /> LEACHING'LINE [ ] No. of Lines ------------------------ Length of each line-.-------------------------- Total Length ___:____ <br /> e� <br /> 'D' Box ------------ Type Filter Material -------------------.Dep th Filter Material -------------------- ----------------------- <br /> Distance to nearest: Well ------------------------ Foundation :,___-----------_----____ Property Line --..____________--_.-.-_ <br /> ' SEEPAGE PIT [ ] Depth ____________________ Diameter - Number -------------- ------------ Rock Filled Yes ❑ No 0- <br /> Water Table Depth --------------------------------------- --------Rock Size ----------- ---------------------- <br /> Distance to nearest: Well -------------•----•--------------...r:Foundation ------ Prop. Line _-_------------------- <br /> E, IR/ DITION(Prey. Sanitation Permit# ----------- --------------------------------/Date ----------------------------------- <br /> Septic <br /> -------------:-------------------Septic Tank (Specify Requirements) --------------� ---------------------- `t 1 -------------------------------- ------------•--•------- <br /> Disposal Field (Specify Requirements) __ 1,_.. PCS► ___u 'Q---- ----1,.L ----4--k�---k�--SVfv1e----------------- <br /> -------------------------------- <br /> S <br /> / i.r z <br /> ------------------------------------ - _ -_ ----____._._____-_______------- ________.-_-_----____ _ _ _ _-- _-_---_ ----___________________-_------_____-_______.___---___._____ <br /> (Drdw 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{,,, E <br /> "I certify that in the performance of the'work1or which this permit is issued, I shall not employ any person in such manner <br /> as to become blect to Workman's Compensation laws of California." <br /> ` <br /> Signe _- <br /> By -- ---------------------------- --------------- " 4 Title ------------------- - <br /> (If other than owner) <br /> IL L FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY kAII ---- --------------- --- --- <br /> - -------------------------------------- DATE ------ ----------71----------------- <br /> ---- =----- ------- <br /> BUILDING PERMIT ISSUED ------=• ------- - `_-=---- --------------------------------------------------------- - <br /> -------DATE ------------------ <br /> ---------------------- <br /> -------------------- <br /> ' , �. A <br /> ADDITIONAL COMMENTS ------------------------------------------------------ - ----`--------------------------------------------- - - ------------=--------------------------- <br /> ----------------------------- <br /> ------------------------- t------------------------------------------------------------------------------------------------ <br /> ---- 1--- ------- --------------------------- <br /> ----------- <br /> ------------------- - - <br /> ----------------------------------- ±} -------------. <br /> Final Inspection by: --- -----------------------------•----------------------------------------------- ----------Date ----- � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT \. <br /> E. H. 9 1-'6'8-Rev. 5M C, 1 <br />