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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- Permit No. -----7_ <br /> (Complete in Triplicate) <br /> -------------I-----------4"WA---------------- <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San J rq al Healt istr' for a permit to construct and install the work herein <br /> described. This application ' i omp ian with C ,dinance No. 549 and existing Rules and Regulations: <br /> 3 7a-$- f <br /> JOB ADDRESS/LOCA-TTIION _ - --_ _0 __ � � - *�. h4-ry^CENSUS TRACT S_��______________ <br /> Owner's Name _�1G-art__i - w Phone <br /> ---- ---------------------------------------- <br /> Address _ c '-L' K-�- �� City -- a... rii� <br /> Contractor's Name �____2 _ d__-_.License# _ 11313 -)`----- Phone _----_----------------------- <br /> Installation will serve: Residence jApartment House[] Commercial ❑Trailer Court !❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-_ ------- Number of bedrooms __--;.....Garbage Grinder ___ 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 {X 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 public sewer is available within 200 feet,) ( v <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 0p �c _ . _ _ ______________ Liquid ___________� <br /> Capacity /-6-¢ {_ Type C' N- _-y_-__ Material. °'-® ___ No. Compartments ....�.......... <br /> ---------------Foundation ------------ Prop. Line ---`S� ! ---- <br /> nea st <br /> Distance to : Well ____________ "_ --' <br /> LEACHING LINE [ No. of Lines ________.�--________- Length of each line__-__---?g__ Total Length ....... p........... <br /> 'D' Box ___�_----- Type Filter Material ________S_R_Depth Filter Material --------------��_________________________ <br /> Distance to nearest: Well _-___�D___.'_-___-__ Foundation ______l4_t-________ Property Line ----- � _ <br /> SEEPAGE PIT [ ] Depth -___-___________ Diameter ______-______ Number ._________________________ Rock Filled Yes F] 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 /> Disposal Field (Specify Requirements) -------._-__ __________________________ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 becomesubject to Workman's Compensation laws of California." <br /> Signed -------------------------------------------------------------------------- ---- ---------- Owner_,_, <br /> BY -------------------------------------------- 'r�-t..r r_,V------- Title AC;� •L t ar--------------------------------------------- <br /> (If other than owner) <br /> FQR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---je ------- --------------------------------------------------------- DATE --------------- <br /> BUILDINGPERMIT ISSUED ------------- -------------------------------------------------------------------------------DATE ------------------------------------------. <br /> ADDITIONAL COMMENTS - - - - <br /> ----------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ---------------------------- <br /> { -------------------------------------------- ---------------- --------- --- ----- <br /> ----------------- - - - - <br /> --------------------------------- -- -------------- -------------------- ------ <br /> Final Inspection by: --- Dat -.1� : -- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />