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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------- <br /> ------ �/- -- ----------------- (Gomplete in Triplicate) Permit No. - _ln__.�_�3 <br /> 1 <br /> - --%---- 1 _ . <br /> _______-_.____._________________________ This Permit Expires 1 Year From Date issued <br /> .Date Issued ___'�_-L_-_7.3 <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/LOCATION _ ----ILC--------------CENSUS TRACT -------------- ----------- <br /> Owner's Name �% �� r ^------------- ---------------- ------------Phone <br /> Address -- �C-� �� 7= ------17'1 ?4------------ --------- City ----�-7 ------I f�---------------------- <br /> Contractor's Name R-"1'------ � f -.License # _c -l� ' l�J Phone <br /> Install tion will serve: Residenc partment House❑ Commercial ❑Trailer Court F1 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms ________-__Garbage Grinder __-----------_ Lot Size ___-____>______________________-------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------•--•------ -'---•------------Private,( <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 <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 [ ] ------ Liquid Depth __- z___ <br /> Capacity ___L_RUG_a_,__ Type _ Material_���%xeNo. Compartments __ - .......... <br /> O <br /> Distance to nearest: Well ______ ' .._..___Foundation _A15------------- Prop. Line ___ ---------_------ <br /> LEACHING LINE <br /> -----_-__-__-_LEACHINGLINE [ ] No. of Lines ----- ------------ Length Length of each line--- _0 Total Length ______ ob......_... <br /> 'D' Box _ Type Filter Material ----Ik.-..------Depth Filter Material ----------- ........................... <br /> 7 Distance to nearest: Well ----t��__________ Foundation __-___jt d___-________ Property Line ............. ............ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter _______________ Number------------------------------ Rock Filled Yes ❑ No C] <br /> Water Table Depth ------------------------------------------------Rock Size ------------•------------------- A, <br /> Distance to nearest: Well ________________________________________Foundation -------------i------ Prop. Line ...................... j <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _._____--_„__________--------------------- Date ----------------------------------) .p <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------- ----•---------------------------- �y <br /> Disposal Field (Specify Requirements) ----------• ------------------------------ --------- ----------------- ----------•-------------- ...... <br /> ------------- ---------------------------- ------------------------------------------------------------------------------------------- --------------------= =----------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.” <br /> Signeedd,---- ------------ ];-------------- <br /> - ---------------------------------------------- Owner <br /> BYlUL�� --------------------------------------------- Title ----------------------------- ---------------------------------------- <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... -------------------------------------------------------------------- DATE ----5 -'2�- 1'� �------------. <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------- -----------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----- ---------- <br /> ----------------------------------- <br /> -- - ----- -- ---- ------------ -----=------- <br /> - - - <br /> - - - - - - - - - - - --------------� `-��=23 -Final Inspection by: -- ----------------------------------------------------------Date ----- - ----- <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />