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' FQR OFFICE USE: APPLICATION :FOR SANITATION PERMIT <br /> Permit No. .7 _`�`�. <br /> (Complete In Triplicate) -_ .. _-_. . - <br /> ......................................................... _ <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 movie in compliance with County Ordinance No. 549 and existing Rules and Regulations, <br /> I � <br /> JOB ADDRESS/LOCATION ._�. ....... i..... .....__ . ...CENSUS TRACT .......................... <br /> Owner's Name ... . . _ ` ....... .. ... ...� ..c�... .. . _.. .....-.....................................................Phone <br /> Address .r... - -...... •. -•-• ... ...................... City ._.__......_...._...._.....------....... ................................... <br /> Contractor's Name ----------- .`t`4'`�----.-•- -------------------------...........................License # ------------------------ Phone ----------- .................. <br /> Installation will serve: Residence Q Apartment House 0 Commercial Wraller Court 0 <br /> s <br /> I Motel []Other.. . A4 _... <br /> Number of living units:---'-------- Number of bedrooms -..---------Garbage Grinder .----------- Lot Size ._... -_------_. <br /> kWater Supply: Public System and name- ............................................Private <br /> Character of soil too depth of 3 feet: Sand' Siltr] Cloy [] PeatC] Sandy Loam o Clay Loam ❑ <br /> Hardpan❑ Adobe Q Fill Material ._.......... If yes,type ............... ............ <br /> F <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 f ] Size........_____________________ ---------- Liquid Depth .......-..................X <br /> I Capacity -------------------- Type ....----_--------. Material-------- ----•• --- No. Compartments --....................o <br /> Distance to nearest: Wel .....-------................. ------Foundation ----.-- ------ Prop. Line ..._.._.-_---._---- <br /> LEACHING LINE N _- <br /> � <br /> [ ] o. of Lines ------ ----- --. Length of each line............................ Total Length .------- <br /> D' Box ----....=--- Type Filter Material ..........•---------Depth Filter Material ..._..--••_-•...............................j <br /> Distance to nearest: Well ......... ..............Foundation Property Line .......................eo <br /> SEEPAGE PIT [ J Depth ............... ...... Diameter° ...._...... Number:. I...-.--____......._..___ Rock Filled Yes ❑ No <br /> ---" Q) <br /> Water-TOle Depth ..........................___-------------Rock Size ....------------------------_--- <br /> Distance <br /> •-------------- ••--- <br /> Distance to nearest: Well ........................................Foundation .............. Prop. Line .......--------_._ . <br /> REPAIR/ADDITION.(Prev. Sanitation Permit# ............................................ Date .............._---------------------1 <br /> Septic Tank (Specify Requirements) ••-------------•--- ........................................................................................................................ <br /> • <br /> Disposal Field ,(Specify Requirements) ...__ - ---•--- -- -------------- <br /> -•-------- --------------:...._......- ............ ------ ------ ................ ------------------------------------------------------ ........................ <br /> s .....--- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> ii x <br /> Signed _�W�In�='�--------�''w-_._�.. .1-VA------•--------------------------- Owner <br /> By --------- t - '—.................._------•------------- Title _....... ....................... ----•------- <br /> (if of er than owner( <br /> 4 <br /> I:OR DEP RTMENT USE ONLY <br /> . APPLICATION ACCEPTED,BY _-__-.__---- - - - -- -- -- � .3�� <br /> - -.."......................•- -------------------- -- -....""..,. DATE --- �---�--.._.._.__.`-5.�--------- <br /> - - <br /> BUILDINGPERMIT ISSUED -----------------. ..............------ ------._...-------------- ----.-...__DATE ----------------------------------- <br /> ADDITIONALCOMMENTS .................. ----------•--•-•--••------------•-- -•---••---- • -----•-- --------------------_------------------------------------------------ <br /> ------------------------- -----• --- :. 4 <br /> k -------------•------- -•---------......-•----.._.._._._.....------................. ----------•--- ...................... <br /> i --•--_-----•---- -----• % <br /> -- ------ -------------------------------------- ................................. . --------------------------•........... --------......_....._...__........---...... <br /> .. !......_.. <br /> Final Inspection b •-----•--.--•---Date ... •• ............. <br /> P y- ----••-•- --•--- ..._.._.. <br /> EH 13 2h 1-68 He,;. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M <br />