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' FOR OFFICE USE: <br /> -- APPLICATION FOR SANITATION PERMIT <br /> -------- - -��,------- <br /> (Complete in Triplicate) Permit No. o a <br /> -=-------- - -- -- <br /> ------------------------- This Permit Expires 1 Year From Date Issued Date Issued //7/r-_� <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/LOCATION .------23X0_--------- ------- <br /> --------------------------- ------CENSUS TRACT <br /> Owner's Name --------�_'►-1-1e-6----------11—t—N14----------- <br /> T3°'_N-A-s-------------------------------------------------Phone ------'��--�--` <br /> Address ------ <br /> Contractor's Name <br /> ame _--_-__ _� -1-_ <br /> J /---------• Cit <br /> Y ------------- <br /> T _ ---------------------- <br /> --------- <br /> -----------License # ILS-4_a'-7- - Phone <br /> Installation will serve: Residence E]Apartment House,❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----T?G _r_47 �----- --x <br /> -------------- <br /> Number of living units:-___3_-- Number of bedrooms .-_3-----Garbage Grinder ------------ Lot Size ---- <br /> _Q_ `_--._f- _ Q_---__ <br /> Water Supply: Public System and name -___0-)+i.___,_ __ w P -T�1'2 S'F/� <br /> •------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe X 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,) oo <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ J Size -_ Liquid Depth N <br /> .------_--_-•-_-_ <br /> Capacity _-_-------_--_-- Type -------------------- Material---------------------- No. Compartments <br /> Distance to nearest: <br /> Well ------------------------------------Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of each line---------------------------- Total Length -------------- ------------- <br /> 'D' <br /> --__--__ _- ------------- <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line <br /> SEEPAGE PIT [ ] Depth ---- -_-_--_-- Diameter Number ---------------------------- Rock Filled Yes ❑ No i❑ <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) <br /> - - - - - - ----------------------- <br /> Disposal Field (Specify Requirements) __,ftDi?--------err--------Iry--------6_-X--- <br /> ---------tolzv_X-1 - A-"--aC-1•�` <br /> -------------------------------------- <br /> - - -------------------------------- <br /> - ---------- <br /> raw 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: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------------------------------- <br /> ----------------------------------- Owner <br /> By ,c�Qs-:., --------------------------- TitleLt�_ - ` '� <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ---- <br /> - ---- - <br /> ------------------ -----------------------------------------. DATE ---//�._! F�—�------- -------- <br /> ADIDIITIONAL COLDING MMENTS NTSD11 11./----- ----, <br /> --- - - --- --------------------------DATE - ----------------------------------------- <br /> ----------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> FinalIns ection b - ------------------------------------------------------------------------------------- a} <br /> p Y f ��2�-.- ----------------------------------------------------------------Date -- T� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />