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FOR OFFICE US <br /> - APPV. ATION FOR SANITATION PERMIT / <br /> (Complete in Triplicate) Permit No, - --(-Qo?- <br /> ---------------- This Permit Expires 1 Year From Date Issued <br /> 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 /> r - <br /> JOB ADDRESS/LOCATION ----------.gDe9_JF----------G . `7 v-C�'—0-A 3S TRACT <br /> --------------4----------- <br /> Owner's Name 4�---Pte^--- �---- 12S --•-------------------------------- -----------------Phone _?7.0 9-- . --��5--- <br /> Address ------- D �.7 �r ..-� d ® �� -� /��,Q� <br /> City - .cr.� -.cF a"� ----- <br /> Contractor's Name --. '-- � License # 42A-.!F-- Phone - <br /> �- - - Y- <br /> I Installdtion will serve: Residence;KApartment House-F-1 Commercial:❑Trailer Court i❑ <br /> Motel ❑Other ---------------------------------------- -- <br /> Number of living units------------- Number of bedrooms --�------ Grinder y 'S- Lot Size --------____.--- - <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------ -- ---------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ 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 /> rNEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANKSize 457A /0 <br /> - ----- Liquid Depth ----- -----------.----- 4 <br /> Capacity 4:5 --- Type -- Material-- ---------4- No. Compartments - --------------� <br /> Distance to nearest- Well _--t�©Q_---------------------Foundation ----.j!q-'4--------- Prop. Line <br /> i <br /> LEACHING LINE [ ] No. of Lines `/---- T--- _____ Length of//each line__-- .--7P__-__------.- Total Length <br /> D' Box _�_ __-_.__ Type Filter Material __f. -----------Depth Filter Material ---_. 4 <br /> Distance to nearest: Well --,6_0-.........._ Foundation -----457-f--------- Property Line ------------------------ <br /> i SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------ --------------------- Rock Filled Yes [] No i❑ i- <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit K# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------ ------------- -----------------------------------------------------------------------------------------••---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------- ----------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------- ---------------------------------=------------- ---------- C <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 followings <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 lei Title <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY q <br /> APPLICATION ACCEPTED BY --------------------- ---------------------------------- DATE ---/ _,-A- F <br /> - <br /> IBUILDING PERMIT ISSUED ------------------------ ----------------------------------------------- ------ --------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --- ------------------------------------------------------------------------- <br /> ---------------------------------------- --------------------------------------------------------------------------------------------------------------------------- <br /> ----- --------------------------------------------------------------------------------------------------------------- -------------------------------------- <br /> -------------------------------------------- <br /> - <br /> Final Inspection by- ------------- -- r--- __s-_- Dat ~/ '!� <br /> - e -- <br /> / --------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />