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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - Permit No. _�d„ (160. <br /> (Complete in Triplicate) <br /> Date Issued <br /> "i (/�_l.X_--____-._•-______.-__ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described.This application made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION/ '_ _ _ -�._CENSUS TRACT ..........................AT I �Q <br /> Owner's Name 11-' G{ ✓! '--l. f1' Phone <br /> Address !----- ---. City --------------------------------------------- <br /> -r <br /> Contractor's Name ---- -- - nse # Phone ---------------•--•------ - <br /> Installation will serve: Resid ce❑Apartment House❑ Commercial Trailer Court !❑ <br /> Motel ❑Other -------4-__- Y�'?�-_-':-' -- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private[r <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,p�' 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 see age pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK Size. __?�.!zm.... _$_ .__.- _- -- Liquid Depth _.. __y............. <br /> Capacity 3°P6 T e 11, ---Material Compartments --_------- <br /> V <br /> -_•.___-.- ...- <br /> � r <br /> Distance to nearest: Well ------_-�_S ___________________Foundation {..Q_-_____-._--- Prop. Line _..__...__._____.--_-- <br /> LEACHING LINT: [ No. of Lines ------ --------------- Length of each line------1---®-__ --W_Total, Length .__y-� ' .._... <br /> 'D' Box -�------- Type Filter Material _-_--.�_ --------Depth Filter Material __�9-`------------ ----------------•__.. <br /> r � <br /> Distance to nearest: Well ------1-0o---_.-_.---- Foundation -_-/0---------------- Property Line%S-..---........._...._.. <br /> SEEPAGE PIT [ ] Depth -----_------------- Diameter ---------------- Number _---------__-__--_.-_---- Rock Filled Yes ❑ No <br /> WaterTable Depth --------------------------------------- --------Rock Size -------------------------------- �J <br /> to nearest: Well ----------------------------------------Foundation ._----------__----- Prop. Line ...................... <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 ----------------------------- t -- ..Wert <br /> ------ -------------------- <br /> B ---- --- -- 1 -'h--_s----�. t _ -OLZ., Title <br /> Y (J ------ ---------•--------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY,,-:�2r ,S'�7 <br /> --- - - -- -------- -----------------------------------------------------------------------� DATE ---------------- <br /> �`_---�-:--- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------ ------------------------------------ --------------DATE -------------•--------------------- ------ <br /> ADDITIONALCOMMENTS --------------------------------- ------------------------------------------------------------------------------------------------ ................... --- <br /> ------------------------------------------------------------------------------------------------- --------------------------- ------------------- ----------------------------------------­­ -- ----- <br /> ------------------------------------------------------------------------t ----------------------------------------------------------- <br /> ---- ------- - __------ - - - - - - <br /> Final Inspection by: -�Tr� - Q- <br /> ---------------------------------------------------- ---------------_---Date -`- 4r 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />