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FOR OFFICE USE:3c� � s <br /> APPLICATION FOR SANITATION PERMIT 7 V/ 65 <br /> ---------------------------------------------1 A Permit No. -------------------­ <br /> ----------I <br /> � (Complete in Triplicate) - <br /> -------- --------------------------------- ----------- <br /> Date Issued/-7,_--1_T_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 Cquirity 9rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __ _-f._ ------ A-_ - _ _ ------ ---------------CENSUS TRACT -------------- ........... <br /> Owner's Name --------,y1--'-- 1`1 �--- _ Phone <br /> Address ........... -------------------------------------------------------------- City / '-----_-------;-----a�1�7 <br /> Contractor's Name ------------------------------License # ,!` --+ �� Phoney _..._..... <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------- ------------ --Number of living units:_,______ Number of bedrooms ._____Garbage Grinder Lot Size __ r_1 --_--..--.- <br /> Water Supply: Public System and name --------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt{] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe V1 fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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-----------------------------------.------------ Liquid Depth -____---__-•---_-----_- <br /> Capacity -------------------- 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 /> 'D' <br /> __-_-- ---------------'D' Box __.--------- Type Filter Material ________________•-.-Depth Filter Material _-_-_____-_--____-_-.---_-___-.---,_-.._-..- <br /> Distance to nearest: Well ________________________ Foundation _----------------------- Property Line ........................ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 1❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements)----------------- --- - 11---------------- <br /> Disposal Field (Specify Requirements)-----101017Z- __"`"'_ / __.r a _____ <br /> --------------------------------------------- --------------------' q - --- - ------------------------------------------------------------------------------------------- <br /> (Draw existingcih- re wired addition on reverse side) <br /> 1 hereby certify that I have prepared this appli[ation and that the work will be done in accordantef'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 subjectto Workman's Compensation laws of California." <br /> Signed <br /> - -- Owner <br /> By ------ - ------------------------------------ Title <br /> w (Ifo r han own r) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- <br /> - -------- ------------------ --------------------------------------------------------. DATE ---1' <br /> 17-1-(07 --------------------- <br /> BUILDINGPERMIT kSSUED ----- ----------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------- -------------------------- ----------------- ----------------------------------- --------------------------- <br /> -------- --------- ---------------------- -------------------------------------------------------------------- <br /> -------------- ------ ------ <br /> FinalInspection by:. -------------------------------------------------------------------------------------Date -----P'--- ------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C <br />