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FOR OFFICE iUSE: y <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ <br /> Permit No- _l <br /> (Complete in Triplicate) L f - ----- ___. <br /> ----------- -- <br /> . '_ _` .. <br /> ---------------------- This 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> r . <br /> V._ <br /> JOB ADDRESS/LOCATION --. I4-��I_�'-_--_X _____t^.vOC ____-____�-_____ _ CENSUS"TRACT ........ <br /> s <br /> Owner's Name ----- -mljwtkf---:--F-- --SAMD-W------------------------------ --- - ------Phone t <br /> Address ------ � 1 - = '-�--------AV-06 --------------ST -------- City _ -[kY _Ro --------------- ----------•---- -- <br /> Contractor's Name --- "__FB_,_----=--------------------=---= ------------------------License # ---------:-------------- Phone ------`--- <br /> Installation will serve: I Residence ❑Apartment House❑ Commercial ❑Trailer Court (❑ <br /> 1 Motel ❑Other <br /> Number of living units:1_;1-------- Number of bedrooms ____.__Garbage Grinder Na---- Lot SizeE__x_ ; _______________ <br /> Water Supply: Public System ' name _Lft_r"_R0P J�'_C.LTy __ _-.-------------------------- _ Private ❑ <br /> Character of soil to a pth'of 3 feet: Sand'❑ Silt❑ ' Gay ❑ Peat E] Sandy Loam ,e Clay", °m;❑M v <br /> t Hardpan ❑ Adobe'❑ Fill Material 10____ If yes,type ----------- ------------- <br /> (plot <br /> _-__-_____-(PIot 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,) ^ Ilk <br /> PACKAGE TREATMENT [. ]? SEPTIC TANK [ Size_7-_X ®_X 'Z-------- <br /> Liquid Depth �,. <br /> s �_ <br /> Capacity /�Q-___.__ Type M ED_ Material_0dNCRETE.No. Compartments t r�---------- <br /> (A/— <br /> Distance <br /> __:___. <br /> Distance to nearest: Well _ -- :__________________Foundation J0__0 <br /> _________- Prop. Line _.)_ ........ <br /> LEACHING LINELines- -�-- - Le g fi`"of edchfine '_ ` " g s s®h <br /> _-" _ T <br /> _ li <br /> ota[ Lent <br /> 'D' Box/CType Filter Material G __Depth Filterteriai ----- a�------------ ...._ <br /> Distst nce-to nearest: Well :_ Foundation '_6_S.d-____-_____- Property Line ------- <br /> SEEPAGE <br /> _.7__'__SEEPAGE PIT '[.a.]r Depth -------------------- Diameter 1 _:__________ Number _--__- -------------- Rock Filled Yes ❑ Nei❑ <br /> t 3 "! <br /> Water Table Depth ----------------------- <br /> ---- ------------------------Rock Size -------------------------------- <br /> Distance <br /> --------- ------ ----- <br /> Distance to nearest: Well ------ <br /> -------------------------Foundation __________________ Prop. Line ....................... , <br /> REPAIR/ADDITION(Prev. Sanitation Permit#.------------------ ---------------------- Date ----------________________________) <br /> Septic Tank (Specify Requirements) ---------------------------- <br /> Disposal <br /> ---- -------- ------- <br /> Disposal Field (Specify Requirements) - �: -- ----[------ ----------------------- <br /> t;ti a,•,+..» .} .v4k `--�. .,.1 tip„ I <br /> ti �" <br /> _ __________________------------------------------------------------------ -----------------------------------------—------------------------ <br /> _______-_______________________-________.-______ <br /> __________________ _______________________________________________._--_______---__-_______-_______________-_-__! , <br /> (Draw existing and required addition on reverse side) <br /> I hereby}certify1thbt I have prepared this-. will be done in accordance with San Joaquin <br /> County OrdinancesState Laws, and Rules and Regulations of the Sain Joaquin Local Health District. Home owner or licen- <br /> sed agents si.gnatuire certifies the following: <br /> "I certify that ' h'e`performance of the work for which this permit is:iss.u.ed,..lshal.l-not-:em"pl iy any person in such manner <br /> as to b ject to Workma s Com nsatio -laws of California." <br /> I t <br /> Signed --------------- <br /> By <br /> - - ------------!------------------------- Owner <br /> -------------- x <br /> BY ------------------------------------------------------------ ---'------------------------- Title --------------------------------------- --------- ----------------------- <br /> (if <br /> -- - ---------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ° `CSR=a----------1—D --- DATE - - -66_....... <br /> €_. _ ._....."__w ` <br /> BUI LDi'NG-P€RMtT-ISSl1ED— -- � '�. ��.�_ -._..DATE <br /> ADDITIONAL COMMENTS .-._ f-a__ __ - <br /> -- ------ <br /> --------------- <br /> ------------------ <br /> b ----------------------------------------------------- <br /> ------------------------------------------- -- <br /> ----- - ------ --- -- -- ------- <br /> -- --------------------------------- - - -------- '-------------- --------- ----------------- ------- <br /> - - - --- -- -- <br /> Final Inspection by: r ----------------------------1--��- l-------------------------------Date --= 1?1��9f ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> i <br />