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FOR OFFICE USE:f <br /> - .. APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> ---------=------------ ----------- ---------------------- <br /> (, (� Date Issued <br /> -------------------` --- --- ________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the pan J aquin 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/LOCATION _-_____A_vsTtA--------- <br /> _--- - R-�_____________________CENSUS TRACT <br /> Owner's Name ---- -------------------------------------------------- -------PhoneJ��/= J_ <br /> Address --------2-2 --S-7------- ---------WAR_R_e_1W_----A_V_E-.. City -----F?J_1>0_ 4------------------------------------------•------ <br /> Contractor's Name -------- 9---------------------------------------------------------- # ------------------------- Phone ----------------------•------- <br /> Installation will serve: Residence 25(p-artment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other _.------------------------------------------ <br /> Number of living units:__------- Number of bedrooms ---------- Grinder ___ Lot Size _CRIF CE-____---- <br /> Water Supply: Public System and name ---------------------- --------------------------------.-----.-.-------------------•----•--•-----Private <br /> Character of soil to a depth of 3 feet: r Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam [Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material __)`-0__ 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.) )Q <br /> NEW INSTALLATION (No septic-tank or seepage pit permitted if public sevi✓er is available within 200 feet,) <br /> PACKAGE TREATMENT _[ ] -SEPTIC TANK,[ Size----------------------------------- -______ ___ Liquid Depth --__________-.-----.._ <br /> Capacity --- r Type ------ Material-------------------- - o. Compartments ---------------------- <br /> Distance to neares : Well ------------------------------------Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ j No. of Lines ---------- _-__ ____ Length of each line--------------------- Total Length ____.-____---------------- <br /> 'D' Box ------------ Ty e Filter Material --------------------Depth Filter Material ______-___-__----------------------------- <br /> Distance to nearestd Well ________________________ Foundation ------------------- ____ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth _-_____________-_-_u Diameter ________________ Number ___ ------------------ -___ Rock Filled Yes '❑ No <br /> Water Table Depth !!�-----------------------------------------------Rock Size ---------- --------------_---- <br /> Distance to nearest ell __-___________________________________Foundation -__Y__ <br /> __________ Prop. tine -____-.-__------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit -_____________________________ Date ____._-_________ _____...____) <br /> Septic Tank (Specify Requirements) -------- --------------------------------•----------------. ------------------ ........ <br /> Disposal Field (Specify Requirements) .___�01UL .�___-�-----------, (�_'� lrlh�=------�`�� -------------------- <br /> /�------r0_R------- X4.1 A17-`_a ----- ---- --------- --- ---------------------------- ----------. <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 certi y n the peryWan' <br /> c of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to a subject to s,. pensation laws of California." <br /> Signe - Owner <br /> -------------------•--------- <br /> By ---- -------`------------------ - - -------------------------------`-77 jq7 --1 Title ----------- ---------------------------------------------------- <br /> (If other than owner) <br /> e FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . . ----- = DATE5_ 2_: 72_- <br /> BUILDING PERMIT ISSUED --- ------------------------------------------------------ -----------------------------------DATE <br /> ADDITIONAL COMMENTS ------ -- - ------- ------------------- -------- ------------------------------------------- <br /> -­----------------- <br /> ----------------- <br /> - P <br /> ------. ------------------------------------------------------------------------ <br /> -- --- ------- .J " <br /> Final Inspection _Date __-_ -_____ Q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />