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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ - - = '`; / ; <br /> - - --------'--------------------- Permit No.(Complete in Triplicate) �� -- -------- <br /> _--__-_-__-__---_-_-__------------------__--- This Permit Expires 1 Year From Date Issued Date Issued <br /> ---- <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 wi County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-...1 I-3—T rT ---- ----------------CENSUS TRACT -------6--- ---- <br /> Owner' -s Name ------- t A -- ---- --- - ---- ----------- -- ------------ -- -Phone ------ <br /> Address -------- ------------------------------------------------- City ------- - N_T. ------------------------------------ <br /> Contractor's Name4�3.__ T License # Phone <br /> Installation will serve: Residence J2-Apartment House-[] Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----1------ Number of bedrooms o-Z, - Garbage Grinder��d-,--- Lot Size --- ----------------------- <br /> Water Supply: Public System and name -------------------------------------------•---------- - - -------Private Q'— <br /> Character of soil to a depth of 3 feet: Sande✓ silt C] Clay F] Peat El 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ---------__.____•-_-__-. <br /> Capacity ------------------- Type -------------------- Material---------------------- .No. Compartments ................. --- <br /> Distance to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line ...................... N <br /> LEACHING LINE [ ] No. of Lines ---_---____-__-_ Length of each line---------------------------- Total Length --------- .................. <br /> 'D' Box -------------- Type Filter Material ____________________Depth, Filter Material ---_......................._................ <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] 'Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No 0 <br /> Water Table Depth ------------------------------ Rock,Size -------------------------------- <br /> Distance to nearest: Well -------------------------------------------foundation ____-______-___--_.. Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit t# _______---_-------------------------------- Date --'______-_____________--___-_.-.._) J <br /> Septic Tank (Specify Requirements) ------------------------------------------------------ -- -------- --- - --------®------- T--------------------- <br /> Disposal Field (Specify Requirements) __ _._b•�t2'JIL._._ 'i'✓1D1-- -- •------------------ ---------�-�—�'w--------------------- <br /> -------------------------------------------------------------- ---------------------------- <br /> ------------------------------------------------------ --------------------------------------------------------• --------------- -------------------------------------------------•----•------- <br /> (Draw existing and required addition 6,n,,.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 of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: , <br /> -1 certify that in the performance of the work for which this permit is issued, ) shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed 2 ---- -- --------------------------------------•------------------------- Owner ° <br /> 9 �s <br /> By -------E�-�---0--- - ---------------------------------------------------------- Title <_I'yt �vGCI, <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----�t a------------------------------------------------------------------------. DATE ----- " — <br /> ------------------ -------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------------4--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------- ------------------ ------------- -------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- -- ------------------- ---- ------ - ---------------------------------------------------------------------------------------------------- <br /> - ----------------- <br /> --inal Inspection': <br /> ___ ----------- ---- --- - --- ---------------------------------------------Final InspectioriQ -----------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT* <br /> E. H. 9 1-'68 Rev. 5M-- <br />