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FOR OFFICE USE-. APPLICATION FOR SANITATION PERMIT L <br /> (Complete in Triplicate) <br /> Permit No- ---------------•----- <br /> ---------------- ------------------------------ 4-- 7S <br /> Date Issued -------------r <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/LOCATI N .__ tl <br /> D ----- ---------------CENSUS TRACT --------------------- <br /> Owner's Name •---------------------------------- •-------------------Phone ------ <br /> Address f�° /l.G�l} J ------ ------------ City i1/T <br /> •.y <br /> Contractor's Name -- f +a .l �Jf-,+�_f ------------------------------=--------License #0ZAF6- Phones r <br /> Installation will serve: Residence ❑ Apartment House,M Commercial ❑Trailer Court i❑ <br /> Motel ❑Other - ----------------------------------------- <br /> Number <br /> ------------------------------------- -Number of living units:_------ Number of bedrooms -,3------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 ❑ i <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation-to- wells, buildings dtc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) /I <br /> PACKAGE TREATMENT [ I SEPTIC TANK f I Size ----------- Liquid Depth ____ ----------------- <br /> Capacity -/Oli' -- TYpep� - Material---------------------- No. Compartments -------------------- <br /> 4-",10 <br /> ---- - --------_---- <br /> Distance to nearest: Well ----04;1 --------------------Foundation/g�"------_------ Prop. Line --�j--.�-_-_- ---- 6CC <br /> LEACHING LINE [ ] No. of Lines -----a-------------- Length of each line---z*'a-- ----------- Total Lenugth ��¢-_ ----------- L <br /> 'D' Box ---I.:----- Type Filter Material �w'�- Depth Filter Material --- Z--11---------------------------•- <br /> Distance to nearest: Well --- ------------- Foundation _. ,`------------ Property Line .-----. -----� <br /> SEEPAGE PITDe th -------------------- Diameter -_---------._--- Number ----.---__------------------ Rock Filled Yes ❑ No Q <br /> [ "] p � � N <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------: <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------•-----------_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------- ------------------ Date ---___--- <br /> = -y ` = -- ------) <br /> Septic Tank (Specify Requirements) --------------------------------- - -----------------------------------------:: '-----------------I <br /> Disposal <br /> ---- -------- <br /> Disposal Field (Specify Requirements) -------------- - <br /> -------------- ----------------------------------------=---------------------------------------------- ------------------------------ ----------------------------- ----------------------•-- <br /> -------------------- - - -- ---------------- -------------- ---------------------------------------; <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:- - --- ---ria <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 subjec W anopornptnsation-laws of California." <br /> i ,� -i._.. O w <br /> 4 -- -- ------ -------- '�- ...T.. .. `..� <br /> Signed ..--Q• ---- Owner <br /> „. ... <br /> By ----- ------- -----;' ---------- - ------ ---------------------------- <br /> Tit[e --=='� <br /> (If other than,owner) r <br /> ~FOR DEPAitTMEN°T U5E ONLY <br />' ACCEPTED BY - -- _---------=-=--=----_:: =--------------------------W- --_- --DATE-DAT -------------------------------------------- <br /> APPLICATION 5 <br /> BUILDING PERMIT ISSUED i- --- _ ---------------------- ------ <br /> j ADDITIONAL COMMENTS -------------------------------------- s ------------- --------------------------------- <br /> --; <br /> ------------------------------------- <br /> ---------------------=---------------------------------------------------------------------------------------------------- ------------ <br /> --------------------------- - : - --------------------------------------------- --------------------- --------------------------------- ---- - <br /> rFinal Inspection b ------------------------------------------------------------------------------- ------------------------------Date ` _`- [ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> E. H. 9 1-'68 Rev. 5M <br />