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FOR OFFICE USE: <br /> ` „ APPLICATION FOR SANITATION PERMIT <br /> -------------------=------------------------------------ <br /> (Complete in Triplicate) Permit No:c72___3__.�l�_. <br /> .______.____._____.�.�._ ..___________________ ''�, This Permit Expires 1 Year From Date Issued <br /> Date Issued __'{-1_ .:Z.Z <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 ma/dee in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONNA. L-d-1------ /f 1/ 19---------------------------- ------ --------------CENSUS TRACT -------------------------- <br /> Owner's Name `' �` .✓ f Phone 6 -, ,� �1? <br /> Address - --------- <br /> 1 Q ��'/ ((�� - City --- ---------------`--------G--------------- <br /> Contractor's Name ------------/---------------- ---- ----J__0 -----------------.License #� ;SIj------ Phone <br /> Installation will serve: Residenceb(Apartment House[] Commercial ❑Trailer Court F] <br /> MotelE]Other -------------------------------------------- �/– ,, <br /> Number of living units:__-__.�__-_ Number of bedrooms _____yGarbage Grinder ..____ _. of Size ___-j----'�K..-_-----__--__-- <br /> Water Supply: Public System and name --------------------------------------------- ------------- ;���/fly-�-- <br /> ------• ..---Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 9 <br /> 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK Size-----!� / X_ '� ____- Liquid Depth . ��__........._ <br /> ------------------- ---- <br /> - _.____ Type _ `___- Material._G`�7ofti, No. Compartments ..`�------_---_ <br /> Distance to nearest: Well ______-____________________________Foundation --- Q--- <br /> _-------- Prop. Line f.......... <br /> LEACHING LINE No. of Lines -------J__------------ Length of each line-----___,10 ----------- Total Length -------/0?........... <br /> 'D' Box __ __. Type Filter Material 1e_t __-•_-Depth Filter Material ---1_8--------------------------------- <br /> Distance to nearest: Well ________________________ Foundation __-_��___ -------- Property Line ___..._.._�.._.._.... <br /> SEEPAGE PIT '[ Depth ------ Diameter _35���____ Number ------_/-__-__.__-_--__ Rock Filled Yes ' No 0 • <br /> Water Table Depth -------------------------•--------------•------.Rock Size <br /> Distance to nearest: Well ___________________--____.--__--.___..-Foundation _ld___--__-_ Prop. Line .15................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------------------•---------- <br /> Disposal Field (Specify Requirements) ------------------- ----------------------------------------------------------------------------------------------------- ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 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 ------------ ---- ` -- -�C(If othe n owner) Title 4! ` <br /> ------------------------------------ ---------- <br /> F PA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -._. _. _ DATE _.I –.`,�__ .-_-_---_--___-_-_. <br /> BUILDINGPERMIT ISSUED ------- --- --- --%-- ---- ------- ----------------------------------------------------------------DATE ------ ----------------------------------- <br /> ADDITIONAL COMMENTS ' <br /> -----------------------------------<-------------------- <br /> ------------------------------------- ------- - <br /> �` -------X 6---7�------�- j----------------------------------------------------- ---------------------- <br /> ----------------------------------------- - --- ------ -- - -------------------------------------------------------------------------------------------------------------------------------------- <br /> Final Inspection by: -------------------------------Date --- 1 --- <br /> --------------- <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />