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FOR OFFICE U <br /> p �� APPLICATION FOR SANITATION PERMIT -7,?, / <br /> -----------------------`------------- Permit No: _'3k <br /> (Complete in Triplicate) <br /> OTI________}_ This Permit Expires 1 Yecor From Date Issued Date Issued <br /> ------------------- 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/compliance with County /Ordinance No. 549 and existing Rules and Regulations: <br /> -�- <br /> JOB ADDRESS/LOCATION .--- -[ ,----/ -_--_-_JQ-5W<�Y----...O��--------------------CENSUS TRACT --------------.-..-------- <br /> Owner's Name - Q -------47.0 !- 1-DQA1dA)V#--------------------------------------------I -------------------------------------- <br /> ---------------------------------------- ----------- t� X1.1' --------------------------------------- <br /> Contractor's Name _M- ,- �1A271f S' � � '• -License #a� a- �-�- Phone o2-fikt5_ �- <br /> Installation will serve: Residence gApartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other ---------------------------------------------- <br /> Number <br /> ------------------------------------------Number of living units:---I----- 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 ❑ 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,) <br /> i <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] <br /> Size_c�-, ►_c __1_ ______________ Liquid Depth _S.____......_.-_.... <br /> Capacity A2.00-6-9t Type PCA,5''V Material_,CSU- VQ lo.�Compartments ...;��_..._..`....... 6 <br /> Distance to nearest: Well _-//e7-----_-_-_--.--_----.-Foundation -------------- Prop. Line -------- <br /> C> <br /> _.----- 6 <br /> LEACHING LINE [ ] No. of Lines / <br /> ___ __-____-_____- Length of each line____.�'"�__-__--_--_-- Total Length 190-1........... W <br /> 'D' Box --- -------- Type Filter Material --------------------Depth Filter Material --_--__-...-__-----.-----.---.---_--._.---- Z <br /> Distance to nearest: Well ---/a.0----_------ Foundation .3.S'------------- Property Line ...... <br /> SEEPAGE PIT [ ] Depth -4A-Y--`---_- Diameter �_ai/-_-- Number _---` ------------------- Rock Filled Yes, ( No C] <br /> Water Table Depth --- -----------------------------Rock Size ---4R---------------- ---- <br /> Distance to nearest: Well ­-----------------------Foundation -------------- Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# :"_ ---------------------------------------- Date -_-_-------.--_.-------_----------) <br /> SepticTank (Specify Requirements) -------------------------------------- ------------------------------------------- --------------------------------------------------------- <br /> Disposal <br /> ---------;----------------,,.--------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------- ------------------- ----------- --------------•--------------------------------------------------------------------------------------------- <br /> (Draw existing <br /> 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 ---------- yy------�--,,-------------------------------------------------------- Owner <br /> BY ------- 2- - - --------------------------- Title ------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDBY ----------� d-r - a 0------------------------------ DATE <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------- -------------------- --- ----------------DATE ------------------------------------------- <br /> - ------------------------------------------------------------------------ <br /> ADDITIONAL COMMENTS --____ _---_ <br /> ---------------------------------------- ------�T %'- <br /> --- --------------------� � --------------------------------------------------- <br /> ---------------------------------- ---------- �' --- <br /> Final Inspection by: ---- Date ���_7� <br /> SAN JOAQUIN LOCA,h HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />