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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------------ --------------- <br /> 3 3 ____ (Complete in Triplicate) Permit No. <br /> low D <br /> [ "v <br /> Date Issued <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``----------i--a a--0- a-----------J� -fie c .-------------------------CENSUS TRACT -------------- --------,-- <br /> Owner's Name - Z. 1 .k_1a._,,-s---------------------------------- <br /> Phone = <br /> Address ----- 4' ------- City -----------------------------------------------------------------•--•---•.- <br /> Contractor's Name c rz- - '--------- -----------------------------License #a112 ;FPhone <br /> ------------I----- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----E----- Number of bedTzp�mss __...Garb_a�7gee Grinder r1 ----- Lot Size -------------------- <br /> Water Supply: Public System and name — '' -= 1- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt(r Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe V <br /> Fill Material ------------ If yes,type ---------------_-_----.-__- <br /> (Plot plan, showing size of lot, location of system in /elation 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,). U <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size-----------------------------------.------------ Liquid Depth ----_--------_-..,..... <br /> Capacity ------------------- Type ------------------- Material---------------------- No. Compartments ------•--------------- <br /> Distance to nearest: Well --------------------------------_--Foundation ---------------------- Prop. Line -.- .--_-_.._-- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ............................ <br /> D' Box ------------ Type ------------------- Depth Filter Material ------------_------------------ ........ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --_------------- ------ <br /> SEEPAGE PIT [ ) Depth ----------- -------- Diameter ---------------- Number ------ --------------------- Rock Filled Yes '❑ No C]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 /> /-- /� �/ <br /> Disposal Field (Specify Requirements) -----4 . .........l <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 /> �j <br /> By --------------------- = �"iv '_'- ------------------------------- Title /a�I =�' 1�--` <br /> f o er an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ,Q--Y -----� --------------------------- DATE <br /> BUILDINGPERMIT ISSUED ----------------------------------------- -------- -- ----------------------------------------------DATE ------------- ---------------------------- <br /> AQ,pITIONAL COMMENTS -------- <br /> ------------------------------------------------------------------------ ------------ ...--------------- <br /> f <br /> ---------------------------- <br /> Ay <br /> _ <br /> _-.-_ - _ -- .i -. _�--.-.- .. -_.-...._-_--------..___ -------------------------------------------------- <br /> --... -. _. <br /> -_� .t. - - - - ----- ------------------------------- -------- <br /> -- -- --------------- <br /> ---- <br /> _____________________________________ ____________________ -------- <br /> ____ __ _ _- ---------------------------- __.-----------.----------------------------- _------ --- --------- <br /> .. --- .-.-.---- <br /> ____________________________- ------- -------------- ------- _ -------- . .- ----- - --- -. - _...-..__.-__--.____--...____-_-..-.---__-_�_ .....\ �� _ - ..- <br /> ... . <br /> Final Inspection by; ------�`--------�. ------ - --- -- ------ - ------ --- - - ---------- ----------------------------------.Date ---- --1---- - --------- -- -----t------ <br /> OA UIN OCAL HEALTH DISTRICT (r •' <br /> \ r <br /> E. H. 9 1-'68 Rev. 5M <br />