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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. .__.�....... <br /> .....Zr <br /> Dare Issued <br /> . <br /> fi•• SFS <br /> ...--_...---•............... This Permit Expires I 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 Cou Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION. .. _ :-�$�_ ..` ._ 1 ' 4�;,•• •� .-.-.. O}C: .._....CENSUS TRACT <br /> ------- ......-......•....... <br /> rte-- <br /> Owner's Name -- ..- . .__ , a.55'.................................:.................. Phone . �i.�.. <br /> Address ..--... .y 4 ' -._� 4�. 1,-2c _.. c.. -.__. city�i��........................•.................. . . <br /> Contractor's Name ------- ,..License 94E '�j� ._ Phone <br /> Installation will serve: ResidencQNAPartment House❑ Commercial❑Trailer Court 0 <br /> Motel 0 Other �.:�.1.�. .___ .tma. { <br /> Number of livingunits:_..__ <br /> � Number of bedrooms .:...._Garbage Grinder ....._...... Lot Size ........ Aclae,.S....... <br /> Water Supply.. Public System and name ' <br /> Private � 010Character of soil to a depth of 3 feet: Sand❑ Silt o Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan❑ Adobe 0 Fill Material ............ if yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse sale.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) <br /> PACKAGE_TREATMENT [ SEPTIC TANK'bQ ize_. 2L /_-- -- r <br /> _..._--•-• •---••• Liquid Depth . ...._....... <br /> 4 <br /> Capacity tY <br /> . .. _ No. Compartments Z............. <br /> w Distance to nearest: Welt ...._:......Foundation 10-_ -- Prop. Line l ov <br /> LEACHING_LINT: _ __ <br /> No. of Linei�r��---------------Length pf eadt. ine..---- ��.r.........• Total Length _..R�._'.70............ <br /> s ._ -C� ..._.. ._Depth Filter Material �.. <br /> k••... Foundation .- -- -*� �.. <br /> 'D' Box ........----- Type Filter"Ma#erial n _�-••----------. Property.Line ..,��._.......... <br /> i <br /> Distance to nearest:`Well t°? <br /> .SEEPAGE PIT Depth.'—.---. <br /> _ ` - - •• ' <br /> [ ! Depth -------------------- Diameter ..... .......... Number --.-------.--_-.....__..-- Rock Filled Yes ❑ No ❑_� � <br /> _ Water Table"Depth -------------- --------•--------•••• ...........Rock Size ................................ <br /> Distance to nearest: Well ...-----•---•••••-••.................•..foundation .................... Prop. Line ....:.----............ <br /> REPAIR/ADDITION(Prev. Sanitation P6Riir <br /> ­-------------------------------------- --_-_---- Date ..................................... <br /> ) <br /> Septic Tank {Specify Requirements} --------------•.. ................. <br /> .. .............•-----••......... <br /> Disposal Field (Specify Requirements) --------............................... <br /> ------------------ <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 to 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 "tanner a <br /> as to become subject orkma 's Comensation laws f California." a <br /> Signed .r- ,a1?1i-- r.a_s 'c� 'fix <br /> --- ---------- -- ----------- -- <br /> By ---- •----...----•-•----•-•----•------• ................-----.•.. . Title _ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY ....... ....:DATE ...,..5 .�P l -. ..,�....- . . ._ <br /> BUILDING PERMIT ISSUED--•-------._--•-------------••_-- DATE <br /> ADDITIONAL COMMENTS ................... <br /> --- -------------•--••--- •---- -- ....---- ----------- --..--........-----........-._. <br /> --------------------------------'-----------------------'------------- -- - - - <br /> 3. . <br /> .-.'...- -F- -•'•.----• <br /> --------------------"----'-'""...-.."----...._-•---'""---....._-....----•••--•-----................--------•- -•--------------.------...------------ _ <br /> Final Inspection by: �'• ---------------- -----------............. •- --:..-..---------•-Date .... <br /> f� ...-. ...... <br /> . lrli 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT._' � = Au B�7$ 3M"`� <br />