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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITm ; <br /> �} <br /> --------------- <br /> Permit No. _I_---------(d------ <br /> (Complete in Triplicate) �1 1 <br /> - ---- -------------- Date Issued <br /> -------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son 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 Regulatiahs: <br /> JOB ADDRESS/LOCATION - 1-------L------13----- 1 � t CENSUS TRACT - <br /> A/ C µ 1�1 - -------------------Phone=----------------------------------- <br /> Owner's Name -_-1 l-i--[- ----- - �-----�--------/--/V---------------- _ - -- <br /> Address _ / -=-[/- k -{ a - - - City -{ °►/�G - 71 - <br /> �J -�2r/- --�' ----------=-=--------License -L- �� � Phone ----------------------------- <br /> Contractor's Name --- ---- - _ _ _ <br /> Installation will serve: Residence®Apartment House❑ Commercial oTrailer Court C] ' <br /> Motel ❑Other------------------------------------------- <br /> Number of living units:----- Number Number of bedrooms ______Garbage Grinder ------------ Lot Size ------6� ------------- <br /> Water Supply: Public System and name ------------------------------------------------------— ' -== ---------------------------Private �J <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ - *Sandy Loam.,❑ Clay Loam <br /> Hardpan❑ Adobe ❑ Fill Material ------------If yes,type--------------------------- <br /> -7' <br /> (Plot plan, showing size of lot, location of system in relation to wells,ebuildi�gs, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available wi in 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I I Size-------- -------- ---------------------------- quina Depth _---------------_ -------`? <br /> T - tenial`------ -----------_ No. Compartments -----_-----------_--- <br /> Distance to nearest: Well -------------- ----- -------------Foundation ---------- --------- Prop. Line ---_:.---------------- <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of d, linea------------°------ Total Length ---------------------------- , <br />' i .4 <br /> 'D' Box ------------ Type Filter Material - -----------------Depth,.Filter M ial -----------------------------•---- ----- <br /> -r <br /> Distance to nearest: Well ----------------- ----- Foundation -'_-----{------- --- Property Line -----_--__-_______------ <br /> SEEPAGE PIT [ j Depth Diameter --------------- Number-"-�_'_______t-____- Rock Filled Yes '❑ No <br /> Water Table Depth ---------------------- ------------------------Rock Size ---- --------------------------- <br /> a <br /> Distance to nearest: Well ------------- --------------------------Foundatio _____------_-_------ Prop. Line ------------------.-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#-------------------------------------------- Date ----------- --------- --------- <br /> Septic Tank (Specify Requirements) --------------- ----- - - -------=------------------ ---------------------------- <br />. Disposal FieldSpecify R uirements) •__X'�__ .-.----� n �Q �� � � e <br /> .rte - -- <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 in accordanat with Sin Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or 1'icen- <br /> red 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 t Work 's Compensation laws of California." <br /> Signed .--------- Owner <br /> By -- --- ------ ----- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTED BY-------- --- ----------------- ----- DATE ------?7.:15 ...... <br /> + BUILDING PERMIT ISSUED ---------------- -------------- --------------•-----------------------------------DATE ------------------------- --------------- <br /> ADDITIONAL COMMENTS <br /> t <br /> -- --------------------------------•--••---------- -- <br /> ��pp --------------------7-::; --� <br /> FinalInspection bY= -------------------�/_�s�.� ------------•------------­----------------------------•---------Date __._..__------------- �---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />