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FQR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 0.1-------------------------------------------- <br /> (Complete in Triplicate) Permit No: <br /> -------------------------------------------------------- <br /> Date Issued ____-Z3__-_7/ <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 Ordi ance No. 549 and A 'sf+ng Rul and Regulations: <br /> JOB ADDRESS/LO TIQN . .w- -----`-V Y� `°� "'�5--- - CENSUS TRACT -------------------------- <br /> Owner's Name '"�'�� u C G ------------------------------Phone <br /> Address ------ ------ -- - Cit --------------------- -....... <br /> Contractor's Name ___ j --`-�� _ <br /> -- ! License # � ._s z Phone <br /> Installation will serve: ResidenceZ4Zpartment House❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑Other -------------------------------- ----------- <br /> Number of living units:-----E------ Number of bed oms ._ ----Garbs e Grinder Lot Size -,�(�'_.X___l_.l _______________ <br /> Water Supply: Public System and name ---- -- - Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material _ILI 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK[ j e--------- 5-----______- Liquid Depth _ ______----- <br /> ------------ <br /> Capacity _1-2 ' Type ateriaf h« // o. Compartments _ <br /> Distance to nearest: Well _____." -- -------- --------------Foundation _l__ �_________ Prop. Lines __,_____----__ <br /> LEACHING LINE [ No. of Lines -----�----------- Length of�each Iine_1Kn21k�_ Total Length / d.l__.______._ <br /> D' Box _� _ _ Type Filter Material l/t" __Depth Filter Material ----6 _ <br /> � ------------------- <br /> Distance to nearest: Well _.. ---------- Foundation ---4 G-_�--------- Property Line _A-___�------------- <br /> -- _--- Rock Filled Yes <br /> SEEPAGE PIT [ Depth ._ ___ ___ Diameter _ ______ Number ____ _ .____ ___._ --�tdo iQ <br /> Water Table Depth -----------{(m-0-_ _______________________Rock Size __-- ------------ <br /> Distance to nearest: Well ________________________________________Foundation __/ _ --------- Prop. Line ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------- ----------------------------------------------------------------------- ------------------•--------•---------------------------- <br /> DisposalField (Specify Requirements) __-________------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 ---------------------- ------------- ------------I---`---------------------------------------- Owner <br /> By ----------------- lel - ------ Title -- «J.- - � <br /> (If oth r th owne <br /> �" FOR DEPARTMENT USE ONLY <br /> 71 <br /> APPLICATION ACCEPTED BY _W__.&' --- "� -��---------------------------------------------------------------. DATE ----- ------ --------------------------- <br /> BUILDING PERMIT ISSUED ------ --- ------- ---- --- - DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ----------------- '----- r ------ - --------------------- - <br /> - ---- - --------------- --- - - ------- 5 - �- ---- ---� <br /> -- -- ------------------------------------------------------------ <br /> --------------------------------------------- r---- ---------- --- -------------------------------------- ----------------- <br /> ----------------------------------------------- -------- --- - -- -- -- --------------- --- - <br /> - - ----- --- - ---- --- - - -- - --- -- <br /> v <br /> Final Inspection b ------------------------Date --- ----- , <br /> P Y -- - ----- <br /> SAN J AQUIN L CAL HEALTH DISTRICT <br /> cc� <br /> �%� <br /> E. H. 9 1-'68 Rev. 5M <br />