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FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT ' <br /> ---------------- -'�- 7 Z <br /> i-0-------- ------ � - (Complete in Triplicate) Permit No. <br /> ---------=------------- - --------------- --------------- <br /> Date Issued __ -. _/.=..7.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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._ Q , ____ ,1/ �_____/ ---------------------------------------CENSUS TRACT --________._-..---_--____ <br /> Owner's Name 9-P,,C----------- -AAZW----------------- - ----------------------------------------------------------Phone _0_e3.—S%72------- <br /> Address � �T�. il✓,S /.�1�'. --------------------------------------- City .5� - � ��Y <br /> Contractor's Name ---/ "-° ...... ' ' L'.__�5:,�4'<__.______.__.._____._.License #� 7r��5 ---- Phone <br /> Installation will serve:. Residence Q Apartment House❑ Commercial []Trailer Court [3 <br /> Motel ❑Other ------------------------_ --------- ------ <br /> Number of living units:---/------- Number of bedrooms 2.------Garbage Grinder W1S__--- 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.) \j <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1•• <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ----.--------_---------- <br /> Capacity <br /> _____- .__-__-Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ___________________________________Foundation ------------.-------._ Prop. Line -----------.......... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_-___-_-_______-___..y_-_- 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 ---------------------------- Rock Filled Yes ❑ No 0 <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 /> � �r <br /> Disposal Field (Specify Requirements) ______ 9_-_,80,y......&11____,4AV;FeW__. __,,,I�9_ ..v-____..0L-__,9s'33--.._...__ <br /> ------------f -f' � /t'�4j------------------------------------------------------------------------------------------------------------------------------------------------------- <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 following: <br /> "I certify that in the pert mance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become su ct t man' ompensation laws of California." <br /> Signed ------ - ------ ------ -------- - -------------------------------------------------- Owner <br /> BY -- ----- --- ---- -------------------------------- Title <br /> (I er than owner) <br /> O -RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- -----------------------------------------------. DATE ----- - / - Y:------ <br /> BUILDING PERMIT ISSUED ----------- - ----- -- - - -------------------------------DATE -.-_-_.-_-__-__-. <br /> ADDITIONAL COMMENTS <br /> ------------------------------------- ------- -- -------- ----------------------------------------------------- ---------------------------------------------------- <br /> Final Inspection by: Date <br /> AN JOAQUIN LOCAL HEALTH DISTRICT ( �\/ <br /> E. H. 9 1-'68 ev. 5M <br />