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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT y <br /> -------- 1- -------------------- = <br /> " ------------------------ (Complete in Triplicate) Permit No.7/ -7-3----- <br /> Date Issued 19:_.J-._l <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. 5,49�and <br /> ,existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO �7` , Q-J��--ww =---�'��� - ""� ? � r '"" CENSUS TRACT •-----`.------- ----------- <br /> Owner's Name .-----------0- �'v_l--C Phone .Q ..7'�,3 <br /> Address _-------------� - - - -----� City ---- -- <br /> Contractor's <br /> �. c <br /> Contractor's Name ------------ -- -----0- s�07?----------------License #/G . Phone ----------------------- <br /> Installation <br /> -i------- ' 6bInstallation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court !E1Motel [7 Other _e �...�L W_ _4_V._ <br /> Number of living units:------I---- Number of bedrooms ---�Z.Garbage Grinder ----------.- Lot Size --------------------------- ----••-------- <br /> Water Supply: Public System and name ----------------------•--------------------------------------------- ----------------------------•-------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt M, Clay ❑ Peat❑ Sandy Loam Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ------------------------ <br /> (Plot <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-------Irl --------- -------- --- Liquid Depth --.-_._..----------------- <br /> Capacity lu _ Type _J G _ Material-._�- °4�' - -__ No. Compartments .-'Z. ........... <br /> r <br /> Distance to nearest: Well ------tS—_:f"--------------Foundation`_ _. .-.-.- Prop. Line <br /> 41 <br /> LEACHING LINE No. of Lines ------4Z------------ Length of each m/ine__.-.._. �. Total Length ,_ ............... <br /> 'D' Box ---c/ Type Filter Material -lam-...Depth Filter Material ---/I .�-........................... <br /> ► S-i <br /> Distance to nearest: Well ----SO-_�'------ Foundation __-.�Q__'t------- Property Line. ._._ ....-.-,'L.......... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .._.._......................__-._._-.---- Date ---------------------------------- <br /> Septic <br /> ------- .--.------- .-_---Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) -----------_ --.---.---__-._----------------- <br /> -------------------------------------------------------------------- --------------------------------------------------------- ----------------------------------------------------- ------- ----------- <br /> ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------_- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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: <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 -------(--t--M-- -- -------- t Owner <br /> By ------------- - -------- -------- ----------------------------------- Title -------- <br /> (1f other n owner) <br /> FOR DEPARTMENT WV ON4Y <br /> APPLICATION ACCEPTED BY ---- ----------------- ----- ---------- ,----- --------------. DATE --- - �r------------------- <br /> BUILDING PERMIT ISSUED ----- ------------------- ----------- ---------- - ------ ---- --- -------------------------DATE ------------- ----------------------------- <br /> ADDITIONAL COMMENTS - ------------_ ---- <br /> -------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ <br /> --------- - -------------------------------------------------------------------------------------------- ------------ - - ----- <br /> Final Inspection by: --------------------------------------------------------- ------------ •. -✓!r`--------------Date <br /> SAN JOAQUIN .LOCAL . E H DISTRICT <br /> E. H. 9 1-'68 Rev. 5M `"L <br />