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FOR OFFICE USE: '° APPLICATION FOR SANITATION PERMIT <br /> r�- 7c� 'J 7e2 SG <br /> ------------ <br /> Permit No. _ '- __.. <br /> / (Complete in Triplicate) <br /> L <br /> ------- <br /> -- '0-------------I--------- <br /> This Permit Expires 1 Year From date Issued <br /> 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 compllan with C my O inace No. 549 and`existing Rules and Regulations: <br /> �J` 4 . <br /> JOB ADDRESS/LOCATION `_�J 0-3 <br /> JOB - --------- <br /> ----"=-�;-�J - - - -- ------------- ------------- ----CENSUS TRACT .-- <br /> - <br /> Owner's Name Phone- <br /> --------------- - - -- <br /> Address -------------�iO-0-__ t.----- - --- -- ----- ------------ City --- ------- 1f` GGf <br /> _______-License #.:1Pa !l_------ Phone 7__66-- 7 <br /> --------------------- <br /> Contractor's Name ----------- <br /> --f---- --- ---- - ---- -----�--- --f���-- � ---- :-- ' <br /> Installation will serve: Residence AApartment House❑ Commercial.:❑Trailer Court ',❑ <br /> Motel ❑Other --------------------------------- -•------- <br /> Number of living units----.___/ Number of bedrooms __'Z__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 Loom ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe-[—] 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 side.) v. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public'sewer is available within 200 feet;) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-----------`------------------------------------ Liquid Depth ----------------.--------- 0 <br /> q ' <br /> Capacity ------------------- Type -------------------- Material=---------- `--- -- No. ;Compartments <br /> Foundatiorn}� -_.------_----- Pro Line . '-------------•-•.-- <br /> Distance to nearest: Well _______________________------,- r_. P .. - .` <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each hne;:x__.- ::_____ ___-Total- Length ,_____.__.___..______._.__ <br /> 'D' Box ----------- Type'Filter.Nafierial --------------------Depth Fitter Material _____________.- _ <br /> Distance;to nearest: Well ____________________--- Foundation .____`° `____ ----.-- Property Line'---______.__._----._..._ <br /> SEEPAGE PIT [ ] Depth _`_______.__- Diameter. Number ---------------------- Rock Filled Yes ❑ No 0 <br /> t � <br /> Water Tbble Depth ---------------------------------------__- ---Rock Size ----------------- ------ <br /> ta� - <br /> Distance-ta-near.est:.Well_---------------------------•------) i Foundation ---i--------- -•..-- Prop. Line ----.-----------_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- -----. Date ----__---------------------------- <br /> ) <br /> t <br /> Septic Tank (Specify Requirements) ------------------------------------- ' --------------------- ---------------------------_.---------------------- <br /> Disposal Field (Specify Requirements) -------------------- �, _ T <br /> _­_ ___ <br /> __________ <br /> _ _ _________ <br /> i ' __ <br /> - <br /> . .� `e. - <br /> �.-- ..(.Dra.w.existin and_re uired.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 for which this permit is issued, I shall not employ any person 1n such manner <br /> as to become subject to-Workman's Compensation-laws of California." <br /> Signed e✓ 3 +'.1 ►� __t `-1 - ` �3 ---- . neer 4 <br /> g <br /> Ow <br /> BY -.......... <br /> --- -- ---------=' - ----------------- Title ------- --------------------- -------------- <br /> (I ot-er an owner)---�--.--�--_ . --____,�.-.- . Tiw �— <br /> FOR.DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY=- - ------ " "_ �r ---------. DATE ------40`1e_____7_�?--------------- <br /> BUILDING PERMIT ISSUED - -" - ------- DATE <br /> ADDITIOCOM ENTS ---- ---- - ------------------------------------------------------------------------------------------=----------------------------- <br /> ------- ---- <br /> !_ <br /> -------------------- ----------- - -- Date <br /> ---- - <br /> Final Inspection by: __ ___ _ - � �� <br /> ----- - --- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />