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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .____ -_ <br /> ----- ---------------------------- (Complete in Triplicate) Permit No. _7_ __1o.3__y <br /> -------- - <br /> '� �t Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> I/ 1 -------------- <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 <br /> compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ppf/ r -- <br /> Owner's <br /> - - --- -- --------------CENSUS TRACT -.-_---_. <br /> - ----�- <br /> ---JOB ADDRESS/LOCATION ____ _-- ----------®- ---- - --------- -- <br /> Owner's Name ------ - -- - - ------------- -- ------------ - --- - ------------ ------ _ ----Phone _rV5_ 3 <br /> Address ------------- 6---;---.� ---- ---------------------: <br /> city ---- ----------------------------------- <br /> Contractor's Name ---- -------- --------------------------------License #1�-���------- Phone -----��7 <br /> Installation will serve: Residence n<Apartment House❑ Commercial ❑Trailer Gourt i❑ <br /> Motel ❑Other ------------------------------------------- 0 <br /> Number of living units:--I------- Number of bedrooms ----f------Garbage Grinder .. _ __._ Lot Size --;?o--- -6------------ <br /> Water Supply: Public System and name ----------------�..----------------------------------------------- --G-!v --------•--------____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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pylic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT 'N SEPTIC TANK'6e 117 S' e-_-_ ____---)e_/_.� <br /> ----- ----______------- Liquid Depth ___ <br /> Capacity/&V-------- Type - -- ------- Material--- No. Compartments --- ----------•--•-•-• 0 <br /> e � <br /> Distance to nearest: Well _________________-_-______•__-.---Foundation ---1141.---- <br /> ___ Prop. Line ___ ______...___ <br /> i - <br /> LEACHING LINE ?( No. of Lines 01-1---------- Length of each line___47o_____-------_ Total Length lPQ................ <br /> 'D' Box ----Ie"" Type Filter Material A6�_ _.._.Depth Filter Material ---- - ------------­-- ............. <br /> r ' <br /> Distance to nearest: Well ----------______________ Foundation ---/©------------- <br /> Property Line ____.._.___ ........... <br /> ' 6 " <br /> SEEPAGE PIT )< Depth ----�_�- ___ Diameter ___5--------- Number ___:.___;0Z__�_____A� Rock Filled Yes V No 0 <br /> Water Table Depth ------------------------------------------------Rock Size --- -------------------- _ <br /> Distance to nearest. Well ----------------------------------_.....Foundation ---t 0__-------- Prop. Line _._ ................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......... --------------------------------- Date ------------------------------------ <br /> Septic <br /> _______________________________Septic Tank (Specify Requirements) _.------------------------ ---------------------;-------------------------------------------------------------------------------- --- <br /> DisposalField (Specify Requirements) -------------------- -------------------------- =------------------------------------------------------------------------------------ <br /> --------------------------------------------------_---------------------------------------_______------yr-------------------------------------------------------------------------------------------------- <br /> I <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-o# 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 _.--------- .. -- Ow.per <br /> w • '` <br /> -Tit{e <br /> (If othe t an owner) <br /> F94 DEPARTMENT USE OtRY <br /> APPLICATION ACCEPTED BY -------------------------------- DATE -- ---- <br /> BUILDING PERMIT ISSUED ---------- - <br /> -----DATE ------ <br /> ADDITIONAL COMMENTS ______________ ______ <br /> -----------------/-�--I-�---71------- --- -zw --------- ------ ---- ----------- ------------------ -- ---- --- - <br /> -------------------------------------------------------------------------------------------------------------------------------I-------------------------------------------------------------------------- <br /> ------------------------------------ `7 - - -- - -- - -- - - - - <br /> ----------- ---- ----- ---- - - - - - - - - - -- <br /> Final Inspection by: --------- -- <br /> SAN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ��� <br />