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/ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / _c��3 <br /> f�= r53d y <br /> (Complete in Triplicate) Permit No. --lP- ------------ <br /> - Date Issued _e�­_7-_d <br /> ------------------------- - -_ ------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Safi:Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made;incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> Q t e <br /> JOB ADDRESS/LOCATION . -- L� �H/ ---------------------------------------CENSUS TRACT <br /> Owner's Name6� <br /> ----------- n _ Phone <br /> Address .------------------- I- � ff1 ----------------- City --------------`------------------ <br /> 4 <br /> Contractor's Name - e SflTf/ -----------------License # �QD � ��---- Phone7+n�? 6d <br /> Installation will serve: Residence Apartment House❑ Commercial :[]Trailer Court ',❑ <br /> jMotel ❑ Other -------------------------------------------- <br /> Number of living units:----- Number of bedrooms ___51__-._.Garbage Grinder ------------ Lot Size ------------------_________________________ <br /> Water Supply: Public System and name ----------------------- <br /> d! ---- --'--------------- - Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Dti.' ,Silt-E] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam- <br /> ❑ <br /> I <br /> �- --• - - <br /> -Hardpan-❑ --Adobe-K--�(Fill-Material :--- -lfyes,type <br /> (Plot plan, showing size of lot, location of system in gelation to wells, buildings;`etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit•permitted if pul6lic sewer is available within 200 feet,) <br /> l "" ' <br /> PACKAGE TREATMENT [ I SEPTIC TANKi{,] Size---------------------------------------'-)-------- Liquid Depth -----1-------------------- <br />' Capacity -----------------.F-- Type -------------------- MaterialNo. lCompartments -`------___._-__.:.... <br /> Distance to neares't_Well _- ______________---------------Foundation --------------i------- Prop. Line J.------------------- <br /> Q <br /> k LEACHING LINE [ ] No. of Lines l _.\ Length of each line --------I------------------- Total Length :.__ (A <br /> -lWell __ __________________ Foundation _______________-._----- Pro ert 'Line _-_-_________._____. <br />> SEEPAGE PIT [ ) Depth -------- � _{ Di -- Number ----- -.______ _T: `_ Rock t illed..fYes ❑ No .] <br /> Water Table Depth - Rock Size �. �------ ------------------ <br /> Distance to nearest: Well ___ -__-_-"s___-_Foundations`________1----- Prop. Line _____________ ________ <br /> - # <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___--___--_------------------- 11 �_t Date I-_-___--_-----..-.______________) <br /> Septic Tank (Specify, Requirements)--------- ^= y-------- --- ------- -------------------------- ---------- ------------------------- -------------------- <br /> Di s osal Field (Specify Requirements) _- } =. " l Q f � -----/- --- <br /> ----------------------------------- <br /> - -- I------------- ' ------'---------------------------------------------------- ----------- -- - --- <br /> (Draw efisting-an-r equired abdit6_ny on reverse side) <br /> 7. <br /> 3 rt d r- <br /> I hereby certify that f have prepared::this application-and`tl�af' the—work will be done in -accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of 4he San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: ] <br /> k "I certify that in the performance of the work for which this permit is!is ued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of Californid.!' <br /> kSigned ------------------------------ ) - ---------- Owner �,, <br /> By --------------- ---- {�� Title `- 11" <br /> ilf other n owner) <br /> t FOR DEPARTMENT USE ONLYIN - <br /> i , - <br /> APPLICATION ACCEPTED BYE_ __ __ __ _ I-_____--__- __- DATE ________ _____ __ <br /> BUILDING PERMIT ISSUED - `----------------------- DATE - <br /> ADDITIONAL COMMENTS ---T �r ;` ----------- i--------------- f-------------------------------=------------------------- - <br /> I ---------------------------------------------- <br /> I <br /> --------------------------------------------------------------------------------------------- -- ---------------------------------------------------------- <br /> I <br /> y' I <br /> --------------------------- ---- - --------- --- --�.._.._..--------- ,---------------------�---------------------}} � - - - -------------------- <br /> ------------------------------------ <br /> Final Inspection by: .��. _--- - ---------Date k l- <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M 1 <br />