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FOR OFFICE USE: <br /> _ APPLICATION FOR SANITATION PERMIT <br /> ------------------- ��Od <br /> (Complete in Triplicate) Permit No. ___________.._... <br /> ------------------------------------ -- <br /> (------------------------- <br /> This Permit Expires 1 Year From Date Issued 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. Th4tipplication is made in compliance with County Ordin ce No. 549 and existing Rules and R g la 'ons- <br /> JOB ADDRESS/LOCATION -------_____------------------CENSUS TRACT __ `'_ ......... <br /> Owner's Name --- s/U,S- - --------------- ------- -----------------Phone?_`16_----46,20 •- <br /> � Q G �� _ <br /> --------------- city.TT'y__Cewjf <br /> C�.��_ : <br /> Address .............. <br /> Contractor's Name .X- ----------------------------------------------------------License ____ Phone �3-----I--o:': ---_- <br /> Installation will serve: Residence g�Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__/______ Number of bedrooms wZ____Garbage Grinder 094'__ Lot Size ------ <br /> Water Supply: Public System and name ----------------------------------------------------------------•----•------------------•----------------------Private I4 <br /> Character of soil to a depth of 3 feet: Sand' ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ____________________________ <br /> (Pl'ot plan, showing size of lot, location f system in relation to wells, buildin s, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer s available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TA [ ] Size-_________________________ ______-_ Liquid Depth ______ -------------- <br /> Capacity -- ----- Type -------------------- Material---------- No. Compartments . ---•----- J <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ..............._...... J <br /> LEACHING LINE No. of Lines __ -------------- Length of each line____ ---------------- Total Length 1_yp.---------------- G <br /> • <br /> 'D' Box '/ _ Type Filter MaterialAWrAsf k_____.Depth Filter Material 1f_____________``.__..._....___........ <br /> Distance to nearest: Well ---46Q............. Foundation /F--/----------- Property Line ............ <br /> SEEPAGE PIT [ j Depth --------------- _-__ Diameter ________________ Number _________ ----------------- Rock Filled Yes E] No C] <br /> -. Water Table Deth --------------------------------------------------Rock Si <br /> Distance to near st: Well ____________________Foundat n -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Per # ------------ ------------------------- --__ Date ---------------------------------- <br /> Septic <br /> _______ ..-------_____________Septic Tank (Specify Requirements) ----------- --------------------------- --------•-------------------------.--------------------------- / <br /> -� Disposal Field (Specify Requirements) .......2-704-"M/--- ____ ____ <br /> . `.€ 77 <br /> �'• - . ,r� . '_ C �,rY ,.--------------------------------------------------------- <br /> Zh ---- ---- <br /> ---- --- -------- -------- -------- --- ---- -- ------- ---- - ----------------------------------------------------------- -------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with ie n Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeowner 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> 3 <br /> Signed Owner <br /> B _ 1 . /✓ <br /> ------------ ----- -------------------------------------- ------ <br /> Y ------- _ - Title � % <br /> (If other than owner) 14/ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY FN - - ---------------------. DATE __ .'3 Cj----------- <br /> BUILDING PERMIT ISSUED ----------------------------------------- --7-7 '------------ ------------ DATE ----------------------------------- <br /> ADDITIONALCOMMENTS ----------------- ------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ - -- <br /> ------------- ----Date ---Final Inspection by: ------- - 9 -- -`---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />