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FOR OFFICE USE: <br /> �., APPLICATION FOR SANITATION PERMIT <br /> �. <br /> - - ---- - ----- -------------------- Permit No. -��- -/------- <br /> (Complete in triplicate) <br /> / Date Issued________ <br /> +'-_ __ __._.___-____ This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATION -VV�a4---j y71---Ss----6 ---------------------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's Name ____° -rP--xA0/7-7t�-------------------------`-------------------- --------------- -------------Aone ---------------------------------- <br /> Address -------- -`------ ---------- `. --------------- City aS� *,or-----------------------------•----•------ <br /> Contractor's Name ------ %'�G _- - - ---------------------.-----_._.__._.License iP0_Vf_�71__ Phoney <br /> Installation will serve: ResidenceXApartmentlHouse,(] Commercial ❑Trailer ort 0 <br /> eMotel ❑Other -------}-----------'--------------------- l <br /> Number of living units:__;_ x'Number of bedrooms . ___�`,Garba4e Grinder � Lqf Size -----Ile_______________ <br /> Water Supply: Public Sys$m and name . �f, jk/ --( j '-6j1f�_ _�_t: <br /> _ _ _ _ Private ❑ <br /> CharaF�er of soil to.a depth of 3 feet: Sand❑ Silt❑ Clay Pkat❑ Sandy L*m ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobek Fill Materidl ------------ If yesf fyp'.---------------------------- <br /> (Plot <br /> _._____________________(Plot plan, showing size of,lot, location of system in relation to we,114, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if puI4i1c sewer is aJailable.within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------_------------------_------------- Liquid Depth _-________----_--_--_- <br /> Capacity ---------- -------- Type -------------------- Material---- No. Compartments --------.............. 4 <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line ___-___-..___-_---___ <br /> LEACHING LINE No. of Lines G_- _--f-_--_________ Length of each line----to-107-_l_-------- Total Length ,t ' ............... <br /> 'D' Box / _ Type Filter Material pll Depth Filter Material /0040y-------------------------- <br /> 11 <br /> s o <br /> Distance to nearest: Well ____""'"__??______- Foundation __lid____.__.______ Property Line -_��______________ <br /> SEEPAGE PIT Depth __�-�---___:_ Diameter . ----_-___ Number -----f_____------_------- Rock Filled Yeso No 0 <br /> Water Table Depth -------0--Z7-------------------------------Rock Size Z---- -- ---_-__-___--____ <br /> Distance to nearest: Well -------r!-=----------------------Foundation <br /> ------- Prop. Line _ ___.__._._____ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) _ <br /> Disposal Field (Specify Requirements) .__.:,_. ______. �� 1_ -__, 'X,r� %a ___ �^ <.�s-_--_-------- <br /> Or <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 fr which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensatitn.laws of California." <br /> Signed ------------------- --- -------- ----- - - -----------------------------------. Owner <br /> By -------------------------- �-------------------------------- Title --- �_ l--- <br /> - - ---------- --- - <br /> (if than owner) <br /> F R DEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY __ _ . ---------------------- DATE ____--3—hA 7_ _____________ <br /> BUILDINGPERMIT ISSUED - ----------------------------------------------------------------------------- ---------- ------.._DATE --------- ----------------------------- <br /> ADDITIONAL COMMENTS _ ---------------------- - - <br /> ---------------------------------------- ------------------- ----------------------------------------- ------=----------------------------------------------------------------------- <br /> - - ------------ --------------- ----- -;------- --------------------------------- <br /> --- - ---------------------------------------------------------- ------------------------------- <br /> Final Inspection by: ---- -- -- ------------------------------------------------------- -----------------------Date f `�� ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />