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- FbR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ <br /> - <br /> Permit No. <br /> --------- <br /> (Complete in Triplicate) <br /> {] , --�'_� <br /> Date Issued <br /> v ----- ------- ---- This Permit Expires 1 Year From bate Issued , <br /> Application is hereby made to the San Joaquin Local Health District for a permitTtoyconstrucfi and install the_work herein <br /> described. T}%is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ."'�.�1___ 9 7 3 //)' /V/ /4/Y - ---R-G1------------------------CENSUS TRACT------ ------------- <br /> ------------------- <br /> Name --------- � „ ------------1�f/C. .�lE�---------- ------------------------------- Phane- fir <br /> Address --- �� ` xre1 /r ----- /7---------------------•--. City �`Gf3 o�V ------------` 4 <br /> Contractor's Name ------/---- ..` - /_-/7- l�`y--- -----SdN-------------------License #I� --"' � ---- Phone ✓ _ -f <br /> Installation will serve: ? ResidenceX Apartment House❑ Commercial ❑Trailer Court '•❑ <br /> ` Motel ❑Other_.___-_ <br /> Number of living units:_._____-.- Number of bedrooms J-------Garbage Grinder Lot Size ----- ---a------------------------------ <br /> Water <br /> -----`------------------Water Supply: Public System and name --------------------------------------------------------------------'------------------------- -•----------- ElPrivate <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt f] Clay E_ Peat❑ 5pindy Loam ❑ Clay Loam ❑ <br /> # 1 ' <br /> Hardpan ❑ t 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> � i <br /> 1 PACKAGE TREATMENT f ] SEPTIC TANK'f I Size-------------------------------- ------ . Liquid Depth .--------------------.----- <br /> € Capacity ------------ ------- Type -------'------------ Material---- ----------`-------- No. Compartments -----= --------- <br /> �` Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .---- .----- c <br /> LEACHING LINE [ ] No. of Lines ________________. ----- Length of each line-------------- __-------_--- Total Length --------_-_-----__-____-_-__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------------_----------------- ------ <br /> Distance to nearest: Well -------------------------Foundation ------------------------_Property Line ------- -------- <br /> SEEPAGE PIT [ ] Depth ._______- Diameter ---------------- Number ~` ""----- -----_ Rock Filled Yes C] No 0 <br /> 7 _ r -.w: I <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> } Distance to nearest: Well ----------------------------- ----------Foundation -------------------- Prop. Line ------------------ ..- 7 <br /> • - fo <br /> r REPAIR/ADDITION(Prev. Sanitation Permit# -•------------------------------------------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------/4fi4*0---------�ts4J'--------- ----- <br /> �,� - �+� ' --------== --------------------------------------------- <br /> -------- <br /> ------------------------------------------- <br /> Disposal Field (Specify Requirements) ______..�� __--.-_-- ___--- -- - - - <br /> ' ��'x / °•1 ' '�r`��' ------ — - ----------- <br /> t i <br /> 4. <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 for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation-laws of California." <br /> ,�- <br /> Signe-. ! -----"�----sv--ill-------------- ---- Owner <br /> IBY P --------- --- ------ ------ ----' ---------------------------- ------ Title ----- ---- ------ ---------------------------------------------------- <br /> (If other <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ________________�_ ---___________ r <br /> -------------- DATE --------4 ------ <br /> BUILDINGPERMIT ISSUED --------------------- --- --------------------------------------------------------------- ----------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------- ---------------------------------------- ----- --------- ------------------------------------------------------------ <br /> ----------------- --------- ------ ------------------------------------------------------------------ ----------I-------------------------------------------------------- <br /> ----------------------------------- ------------------------------------------------- <br /> ------- <br /> Final Inspection by: - �" -----------Date ----------- "-----a ............-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />