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Mow <br />,FSR OFFICE USE: ° <br />APPLICATION FOR SANITATION PERMIT <br />-------------------------- <br />-------------- Permit Mo: -- -------------- <br />(Complete in Triplicate) <br />---------•------- ------ ------ ` - Da <br />p'� <br />This Permit Ex fires 1 Year From Date Issued to Issued <br />-------------------------- ------------------------ P <br />Application is hereby made to the San JoagFii'h 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 />50__iY_QND-0-0-D------ _R TRACT ---&.. S7_-_------ <br />JOB ADDRESS/LOCATI N _�U eOwner's Name -------- ------------ 1E_0.,S--------------------------------------- ---------------!�n_41195_K----------------- <br />0�D CityAddress ------ r --------- &MN <br />Contractor's Name-----Q----------------------------------------------------------License #---------:--- ------ Phone --- •--------------- <br />Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court i❑ <br />/ Motel Other -------------------------------------------- e <br />g ( ❑ !Z ___Garbage Grinder .''-YO-_: Lot Size -------- <br />Number of living units:____ ._____ Number of bedrooms ------- <br />Water Supply: Public System and name --- ------ •--------- --­----------------- ---- ........... ----- Private <br />Character of soil to a depth of 3 feet: Sand ❑ ' Siff ] Clay ❑ Peat Spndy_Loam Clay Loam <br />Hardpan E]Adobe '❑ Fill Material __ . 8 _ _ If yes, ',,'type <br />(PI'ot plan, showing size of lot, location of system in mlation to wells, buildings, etc must be placed on reverse side.) <br />NEW INSTALLATION: (No septic tank or seepage pit p rmitted if public sewer is available within 200 feet,) w <br />PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size ----------------- - ----------------- ------ Liquid Deoth-----------.____---- ----- <br />Capacity ------------------ TYPe ----------------- Material---------------------- hlo. Compartments -----------_-.--•--- d <br />Distance to nearest: Well ________ --------------------------- Foundation ------------- Prop Line ...................... <br />LEACHING LINE [ ] No. of Lines ------------------------- Len 3th of each, line ---------------------- -- Total Length ,___ --._____________ <br />'D' Box ------------ Type Filter Mat rial-------------------- Depth Filter Material .............. ----------- ......... <br />Distance to nearest: Well ------------------------ Foundation -------- --------------- Property Line ____________._--_...... <br />SEEPAGE PIT [ ] Depth -------------------- Diameter - --------------- Number ----- ------------- 1_.------ Rock Filled Yes ❑ No C] <br />Water Table Depth -------------------- -------------------- ------Rock Size -------------------------- <br />Distance to nearest: Well ------------ ------------------------- Foundation --------------- _. Prop. ,Line ...................... <br />REPAIR/ADDITION (Prev. Sanitation Permit # ------------------- -------------------+---- Date ---------------------------------- <br />Septic Tank (Specify Requirements) --- RF-_1l� <br />_-AC~-- ---OLD------- {!-EPWOO-0 ---- -- Ali'-------wu--�------------------ <br />Disposal Field (Specify Requirements) _120Q_..-C.._-ME_FM3-'--------�5 ----1 -X-.---------- <br />----f W -------- 1-------`- r'.� W'lD ------- ----- --------- ---------------- -- ------ <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`iaws, 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------- - ------------ --------------------------------------------------- . Owner <br />' By - - - ------------ -------------------------------------------- Title ------------------ ------------ ---- ---- -- ---------------- <br />If other han owner) <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY -----T-3-0 -------------------'�� ` -- 7 `------- <br />- DATE ----- <br />BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------------DATE------------- ---------------- <br />ADDITIONALCOMMENTS ------ -- ------------------ ----------- ------------ ------------------------------------------------------------;------------------------------ <br />. ----- -------------------------------------------------------------------------------------- <br />-------- ----- ------ - <br />--------------------------- <br />-------------------------- <br />---- - ---- -- -- <br />-- - ----- <br />----------..... <br />- - - -- --- - ---- <br />---------- - ---- --- --- ----- <br />-- --------- - -- -- <br />'Final Inspec ion �/ ---------- Dated 1. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. H. 9 <br />1-'68 Rev. 5M <br />�air■r <br />