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V <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .. <br /> - <br /> -------------------=`--------------------------------- - Permit No. --- ----9(1��-�--- <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- <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 /> 7 <br /> JOB ADDRESS/LOCATION __-_-_!/- �_.�_ -- -- <br /> ----- ' ------------- ---------------- CENSUS TRACT -------------- ----------- <br /> ---___., <br /> Owner's Name -------- <br /> ---- r�r� c `' '` �.0 - --=---------------------------- -------------------Phone -- - —�f ----------- <br /> ------------ <br /> fJ p' '4 - / '------------- S�7f� '.tf� <br /> Address --- ------------------ City --------- = ------------------------ <br /> Contractor's Name ------------- ---------------------------------------------------.License # ----------------------- Phone --------•-_------••---------- <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other -----------I'v - x--------- <br /> �' x l f <br /> Number of living units:____=__ Number of bedrooms ---___..Garbage Grinder ____-______ Lot Size -------------------------------------------- <br /> Water <br /> _________________________ _ __ <br /> Water Supply: Public System and name __-_,_____--- 0,�­4, l.U1,4 r _ _Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam J <br /> w Hardpan ❑ Adobe Fill Material ------ ----- 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;} �-x is T/*(Size_-____.__________________------- ------------ Liquid Depth _-_-________------------ <br /> Capacity -----------------.-- Type -------------------- Material---------------------- No. Compartments --.................... <br /> D'starnce to nearest: Well ____-_-___-_-___-___-------------Foundation ----.----------------- Prop. Line __.______.._____._---- <br /> LEACHING LINE of nes ------------------------ Length of each line---------------------------- Total Length ---------___________________ <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 i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------.------ <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .___._._____----------------------) <br /> Septic Tank (Specify Requirements) ------- ------------------- --------------------------- --------------------------- <br /> Disposal Field (Specify Requirements) -- ---- ------- -.rY---- -----?-2 <br /> ---? <br /> ------------ <br /> - ---- _-- ---------- -- -------- <br /> zS' _3 --- -- = <br /> (Draw e ' ng 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 bec subje(c\t to W�rkma,n s Compensation laws of California." <br /> Signed ---a �. - -� -------�----�--- — Owner <br /> ._ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY cy <br /> APPLICATION ACCEPTED BY -7_7:1:��--- ------- --- ---------------------------------- DATE "'-- ----/--' <br /> BUILDINGPERMIT ISSUED --------------------------------------- --------- --------------------------------------DATE ----------------------------- ------------ <br /> ADDITIONALCOMMENTS ----------------------------- - --- --- - --- --------------------------- <br /> ------------------------------------------------- � ------ --?�__-__________________-_______________-______ =__________ ---- <br /> ------- ---- - -- <br /> --------------------------------------------------------------------------------------------------�---------------------- ------------------------------------------------------------------ i <br /> ----------------------------'------- <br /> •------- -- - <br /> Final Inspection by: ----- ------------------------------ ------ -- - --- 1-- <br /> �- _ .Date --__L-�.- <br /> �OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />