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c <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------- ----------_ Permit No: _� -------------- <br /> (Complete <br /> "----5. <br /> (Complete in Triplicate) <br /> ----------I- ----- ...... This Permit Expires 1 Year From Date Issued Date Issued <br /> - -- ------------ <br /> ------- ------------ <br /> Application is herZy-ma e o t e Sano uin Local H Distr' for�ermit to construct and' install the work herein <br /> described. This application is made�ir�t ryte wit No. 549 and existing Rules and Regulations: <br /> s < , <br /> JOB "ADDRESS/LOCATION . _ __ �----:� �--------� � �-- <br /> CENSUS TRACT <br /> Owner's Name / t one ------ ----------------------------- <br /> ---- ------------ <br /> Ph <br /> Address - ! # Cit <br /> �_ �-�.r <br /> tJ '• . <br /> Contractor's Name ------ ,.11� ~'- --- ---"�--- ---- - ---------•-------- Li - -`� -- �- Phone ------------------------------- <br /> k <br /> ----- ---------------•------- I <br /> Installation will serve: Reside c ❑ Apartment House❑ Commercial [-]Trailer Court ',[] <br /> 1 Motel,❑ Other ----- ..Z�- --x+-----•-------- <br /> Number of living,units:-___`_:_-YN mbar of"bedi'oom's __-______...Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> I I Private <br /> Water <br /> ----------------- ------------------------- <br /> Water Supply: Public,S stem and fame ------------ •_ - -- Private ❑ <br /> f <br /> 3 pp Y� Y �i <br /> Character of soil to a depth of 3 feet` Siynd'❑ Silt❑` Clay ❑ Peat ❑ sandy Loam (� Clay Loam :❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> f <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 [ SEPTIC TANK,[ ] Size----------------------------------- <br /> ---- Liquid Depth ------------ ------------- <br /> j. Capacity ------------------ Type ------------------------ Material---------------------- No. Compartments ----------------- <br /> Distance to nearest. Well ----- --`-------------------------Foundation ---------.------------ Prop. Line --------------------.- <br /> I EACHING LINE [ ] No. of Lines ____________ ________ Length of each line---------------------------- Total Length ,-_-_______-..---_______._.-_ <br /> 4 <br /> Distance to nearest. Well ---_-_-_�-------------- <br /> ____________________Depth Filter Material -------------------------------------------- _ <br /> D' Box ------------ Type Filter Mate <br /> ------------ Foundation ------------------------ Property Line. -------•----------•----- <br /> ' f _______�Rock Filled Yes [� No i❑ <br /> Depth -----�-C?-----_--- Bteametero�___?4_�l1_. Number ----- -- ------- <br /> _ <br /> Water Table Depth _________ _______ -- <br /> ------Rock Size --------- <br /> le <br /> Distance to nearest: Well ----------1-00!------------------Foundation ----.CQ---__-- ---- Prop. Line ....A--------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- -------------------------- Date ---------------------------------- <br /> Septic Tank (specify Requirements) ---------------i ---- - --- -- <br /> Disposal Field (Specify Requirements} _____________ _ __ f e1 /a 't -- o <br /> r; <br /> ----------------- -----------------------------------------j------------------------------------------------------ ---------------------------------------------------------------------------- <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 laws of California." <br /> Signed -------------------------------------------------- --- /� Owners,� f <br /> a-/ �'_ ie-ESC." Title - '"``c�� --------------------------------- <br /> BY . <br /> (If other than owner) <br /> fOR DEPARTMENT USE ONLY <br /> oy <br /> APPLICATION ACCEPTED BY _- ------ -- ---------------------------------------------------------- DATE _ - ------7 -------- <br /> BUILDINGPERMIT ISSUED ------------------------------- -------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------- ------------------------------------------------------------------------------------------------------ ------------ -------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ______________________________________ ____ ____________'_____ ___---_-__-___.__.____----_-__---------------------------------------------------------- <br /> -___-.b__�_ _ -----.-._______- <br /> FinalInspection by: ----- - ------ ------------- ---------------------------------------------------Date ' ------------------- ------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />