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FOR OFFICE USE: <br /> --------------------------------- -------------- APPLIG FOR SANITATION PERMIT Permit No. <br /> (Complete in Triplicate) <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 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/1-OCATION ------- ------5-r�--------- -A -----------------CENSUS TR, 6___-_- <br /> Owner's Name --- /Q-Al IV I-E-7-------- FR-a'-------------------------------------------- --------------------Phone ------------------------------------ <br /> Address ------------------------"3-r-------------------- ------------------------- ....................... City ---------------------------------------------------------------------------- <br /> Contractor's Name ----.License # 44-S_;�16__ Phone5�Z�---Y2�!7..... <br /> ---------------------------_ <br /> Installation will serve: Residence Apartment HouseF] Commercial E]Trailer Court 0 <br /> Motel F-1 Other -------------------------------------------- <br /> Number of living units:____--( --- Number of bedrooms _________Garbage Grinder __1V0__ Lot Size ACP ................... <br /> Water Supply: Public System and name ------------;; - - -------------------------------------------------------------Private E <br /> Character <br /> of soil to a depth of 3 feet: Sand'11 Slit 0 Clay E] Peat El Sandy Loam 0 - Clay Loam 0 <br /> Hardpan F-1 Adobe EJ Fill M6terial ------------ 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 f Size_______________________________- I------------ Liquid Depth ------------------- ...... <br /> O <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments .......... <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ....................... <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: Well ------------------------ Foundation ------------------ -Property Line ...... ............ <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------- Number --------------------: ---- R6ck;Fiffea Yes [I No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------t_ <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prob. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---- -----------------------------1 <br /> SepticTank (Specify Requirements) ------------- ------------------------------------------------------------- -------------------------------------- -------------------------- <br /> Disposal Field Specify Requirements) ------------- ----------- <br /> ------------ ----To------ <br /> ----------------;4xle? r I-----------07-4-------------------------------------------I----------------------------m----�_­------ - ­-------------------- ------------- --------- <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 Son Joaquin Local Health District. Home owner or licen- <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 ----------------------------------------------------- ------------------------ ------------------------- Title -------------I---------------------------------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ON <br /> — 4 <br /> APPLICATIONACCEPTED BY -------- -- - ---------------------------------------------- ---------------------------- DATE ---- ----- ------ ---- _----------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------- --------------------------------- -------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --- ---- -------- ----------- ---------- ----4-------------- --------------------------------- --------------------------- <br /> -------------- ------------------------ ---- - ------7----- --- -------- -------------------------------------------------- ----------------------------------- <br /> /--------------------------------- ---------------------------------------------- <br /> ------------------------------------ --------- --------------- ------ <br /> I --- --------------------- -- ------------------------------- ------- <br /> s 7.f------ <br /> --- --- ------ --- - --- - -- ------- -- ---- -------------------- ---- ---- d -- , <br /> ---------------------------------------Date ----- 3----- ------- <br /> Final Insp - ---- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />