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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � / <br /> -------------------------------------- <br /> k ry (Complete in Triplicate) Permit No. __..-. -:r----- --- <br /> ------------------ 0 <br /> /�., Date Issued <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/LOCATION --------------------------------------s ------------------------------------------------ ---- -- ------CENSUS TRACT <br /> Owner's Name V - / y Phone T- -C= <br /> Address ...b. F9 ,V r j- -----•---{'�. . �----------------------------- City/' �/ I / --- -------------- ---------------- -- <br /> Contractor's Name - 1,.;.-- _; - / --- ------------------------------------License # _7__ �j.-- Phone -J'- -3�5� <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------- ----------------------------------- <br /> Number of living units------------ Number of bedrooms 3------Garbage Grinder ------------ Lot Size Ql --------------- <br /> Water Supply: Public System and name ------------------- --------------------------------------------------------------------------.-Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam X Clay Loam ❑ <br /> Hardpan ❑ Adobe'D Fill Material ------------ if yes, type -.-_-_-__----_-.___-____ <br /> r <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 /> PACKAGE TREATMENT <br /> [ 7 SEPTIC TANK f ] Size--------------------------------------- -------- Liquid Depth ---------------------r <br /> Capacity ` <br /> P Y -- -------------- -- TYPE ----------- - - Material- ---- No. Compartments <br /> Distance to nearest: Well ----------------±------------:------Foundation{___.-_---.---------- Prop. Line --------------- ------ <br /> LEACHING LINE ( ] No. of Lines ----------- ------ Length ,of each line---------------------------- Total Length ------.-------------.------- <br /> 1 a <br /> 'D' Box - Type Filter Material --------------------Depth Filter Material -----.------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------_----.--._.--- <br /> SEEPAGE PIT Depth i <br /> [ 1 P ------------------- Diameter Number ----------------------------- Rock Filled Yes ❑ No , <br /> - ---------------- <br /> Water Table Depth '------------------------------------------Rock Size -------------------------------- <br /> 3 <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line -----------.--....--.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------°--- Date ---_--------`----.-.--_.--...-_---) <br /> SepticTank (Specify Requirements) ---------------- ------------------------------------ --------------------------------------- ----------------.---------------- ----------- <br /> Disposal Field (S ecify Requirements) ------_1 11--_4_,_,l---t4_em,_ --------,----------------- <br /> Z./?�a----- --te a ------- � _A'�------- -� -----------l-d{¢--- ----------- <br /> - <br /> - ------ - - -- - ---------- <br /> l <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 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 in such manner <br /> as to become subject to Workman's Compensation haws of Gedifornia." <br /> Signed . . .. a Owner <br /> --------------- ------ <br /> BY -------- ~- ----- J Title --------------- ------ j <br /> ------------------ <br /> [If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r ------------------------ -------------- ----------------- DATE -(O 2- 601 ------ <br /> BUILDING PERMIT ISSUED ----- ----------------- -------------------------------------------------------------------DATE ..----------------------------------------- <br /> ADDITIONAL COMMENTS - <br /> -------------------------------------------------------------- ------------------/UILOCAL <br /> - ----------------------- --------------------------------------------------------------------------- <br /> ----- ----------------- <br /> --------------------------------------Final Inspection byfS. - ---------------Date --------` - ------------ <br /> SAN JOA HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />