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R OFFICE USE: 4 ' <br /> rAPPLICATION FOR SANITATION PERMIT d <br /> (Complete in Triplicate) Permit No. <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. This application is made lin// _� 7_ <br /> compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._2--��_l.-v-64-,_ <br /> _---- __V_CtZi ------- 2-----------------------------CENSUS TRACT _ ___ <br /> Owner's Name ------Z?O--,6-------- �U_JV_1"_ --------------------------------------------------•-_---------------------Phone ' <br /> Address -2-4n-3-(/------rE----- city nXAT,5_e_,4--- ------------------------------------------- <br /> Contractor's Name ______. _-_/„ ,.____OP. /�P____-_- License # _9_Y� /-Phone - --`-LIS.A." <br /> Installation will serve: Residence WApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- s� <br /> Number of living units:-----I------ Number of bedrooms -�------Garbage Grinder _►V``''D-_ Lot Size <br /> Water Supply: Public System and name ---------------------- ------------------------•----------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E] Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material - _Q`.. 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.) 11* <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) K <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Siz ._._...______________________-_ ------------ Liquid Depth -_-___._------.___,.._- d <br /> Capacity ------------------ Type ----------------- -- Material---------------------- No. Compartments ---------- ----------- <br /> Distance to nearest: Well __________________ _________________Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length o each line------------------------------ Total Length ,__-_--------.-.--_-------- (\ <br /> 'D' Box _ Type Filter Material __ _________________Depth Filter Material ....--.-.-.-..------.-----.--___---_-------- v <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# ------ -- `-------------- --------___-- Date _______.______________.__•_______) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------- ------•---- •---------- <br /> Disposal Field (Specify Requirements) __ ------- . ?_.__._ _�__-- �. '/X- -_--- ---//,Vl'--------- �Iv --- ------- <br /> oe> <br /> w •1�c--------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------_------------------------------------------------------------------------------------ <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 ---- - ------ -- Q Owner <br /> ----------------- -- ----- <br /> BY - -'- Jitle ------------------------------------ <br /> ------ -------- - -------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --�i ------------------------------------------------------------------------• DATE ----- ---`-5-7710----------- <br /> BUILDING PERMIT ISSUED .____-_._-____--_ .__DATE _-___.__._.-_-__._--_ , <br /> ------------------------------------------------------- ------------------ - --------------- <br /> ADDITIONAL COMMENTS -------- ----------------------------- <br /> -------------- <br /> --------------------------- --- - - - <br /> ------------------ ---- ----- - ------------------ - -------------------------------------------------------------- <br /> ----------------------- ----- --------------------- ---------------------------------------------------------------------------------}` <br /> ------------------------------------- ---- -- - - -------------------------- ------ <br /> Final Insp .Date --- --. — <br /> ----------------- --------------•--- ---- -- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />