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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------- Permit No. _7---:5�o3 <br /> -------- <br /> -------------------- (Complete in Triplicate) ---- <br /> ( <br /> ---------=----------- <br /> ---- ---- -- Date Issued -_S_-�S_=7- <br /> __-__-__-_-_____--- -�-1-_-___-____--____ 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/LQ <br /> DDRESS/L ATION .---_;5;qn 1_<--------------------------------------------------------------------------------CENSUS TRACT ------------ <br /> Owner's Name _/_ ���'�__-- 'lf �� _ ___ _ Phone �' ',,-?_?___ <br /> __._ ______________________-___-.__-_-_:_---_-__-____._-__-_-_---______-_ �7____, _.___-_. <br /> Address ----f n ------t- / f <br /> !`/-�--� - _ �----�=�-�- -;---�-------��-�--------•--. City --------------------------- ------------------ <br /> Contractor's Name --------- _iC..___ �laF / 'P____________ _________-_-License # -` �3- � --- Phone <br /> Installation will serve: Residence (RApartment House❑ Commercial ❑Trailer Court i❑ <br /> // Motel ❑Other -------------------------------------------- <br /> Number of living units:------l-_--_ Number of bedrooms ------Garbage Grinder ------------ Lot Size _______________---_--______-__-___________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------•-----Private Pr_ <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 /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size________________________________ -------------- Liquid Depth -_____--__-_____,___-_ <br /> Capacity Type -------------------- M erial------------ --------- No. Compartments - .................... <br /> Distance to nearest: Well ---------------------- _____________Foun ation ---------------------- Prop. Line _---___-__,__-__-_-- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length o each line---- ----------------------- Total Length ----------,................. A <br /> 'D' Box ------------ Type Filter Materia ___________________ epth Filter Material ------------------------------ J <br /> Distance to nearest: Well ----------- ------------ Foun ation --------------- -------- Property Line -_______-.__-__-__-_-__- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ mber ---------------------------- Rock Filled Yes ❑ No i❑ , n <br /> Water Table Depth ----------- --------------------- -------------Rock Size -------------------------------- I <br /> Distance to nearest: Well ____________________ __________________Foundation -------------------- Prop. Line ...................... 17 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___ __ ________________ ________ - Date ----------------------------------) <br /> Septic Tank (Specify Requirements) - ----------- - ---- --------------------------- --- --- -------------------- `--------------------- N <br /> Disposal Field (Specify Requirements) __�LP /_�/__7_n_.-F_____� - '_-_-_ _I9a -___t�'f .�` <br /> f ` �� - ---------_/� - f� _/� <br /> -------------------------- 2� ..L�"? f� 0{ ��`�`r-------- ----------------------- <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 ----- - -- - - � - - - Z1- - <br /> ��--/-A------------------------- Owner <br /> - - - -- - - ----------- -- - -- <br /> BY _ - -------------------------- Title --------------- <br /> -------------------------------------------------------- <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ____ _---------------- DATE .... =- Y_--7_ _..... <br /> BUILDING PERMIT ISSUED -------------------------------------------- ---------------------------------------------- <br /> --------------DATE ------------------ -------------------_--- <br /> ADDITIONALCOMMENTS ----- --------------------------------------------------------------------------------------------------------------------- ----=-------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- ----------- - ----- ---- <br /> Final Inspection b --------- h--_-C-? � -- - -- <br /> �- ------------------------- -------Date - :=1 <br /> P Y: � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />