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FOR OFFI- - <br /> CE USE- - - Permit No. <br /> : APPLICATION FOR SANITATION PERMIT f7 <br /> ------------ --------- ---- -- - -- <br /> {Complete in Triplicatel <br /> ---------=--------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 Qc[e in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---- ---7------1=-ig------& --------- ---CENSUS TRACT -------- <br /> - Owner's <br /> ------- Owner's Name ----- P. 7Z---------�MVW o�-----------------------------------------------------------------Phone <br /> Address ...... )-n-09-pe-__x 2!'------------------- city f�7A��G -------------------------------- ---------------- <br /> Contractor's Name 1- ------------------------------------------------------.License 5-7:Z3�-- Phone R�_-----:--T:r!S� <br /> Installation will serve: ] Residence [Apartment House❑ Commercial ❑Trailer court ,❑ <br /> c` Motel ❑ Other -------------------------------------------- <br /> Number of living units:-------- Number of bedrooms--------Garbage Grinder---- Lot Size ------2-ArAV!�------------- <br /> Water Supply: Public System and-name ------------ -------- <br /> - ----------------------------•-------------------------------- ------------------------------Private lal_� <br /> Character of soil to a depth of 3 feet: Sand❑ ``Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan El Adobe El Fill Material _ Q.-- if yes,type ---------------------------- <br /> 0 <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 'p6rmit ei dl'i if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size----------------------------------------------- - Liquid Depth --------------------,-_--- <br /> Capacity -------------------� Type --------- ------- Material------- -- N . Compartments -------------_------ <br /> Distance to nearest: Well -----------f-----------------------Foundation --------- ------------ Prop, Line ----------_--_------- <br /> LEACHING LINE [ ] No. of Lines ---_ Lerigt - of each line--------.---------_-------- Total Length ---------------- ----------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Mat ial --------------------•----------_---_------ N, <br /> Distance to nearest: Well i------------- --------- Foundation ---------------------- - Property Line -_-------------_-----_- o <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ----- ---------_ Number -------------------------- - Rock Filled Yes [] No i[] <br /> a <br /> Water Table Depth ----------- ------ ------------------------Rock Size ------------- ------------------ <br /> �' z_ Distance to nearest: Well ------------ ---_-----------------_-Foundation ------- ---------- Prop. Line ---------------_------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#`__- ------- - -------------------- Date --------------------- ---.------) <br /> Septic Tank (Specify Requirements)f----------------------------- -___---- ----------- -------------------- ----------------------------------------------------.-... <br /> Disposal Field (Specify Requirements) Q-}^�_---- �--- --- ------------------------------ - ------- -------------- --- ' <br /> ----------- <br /> t�Z7-rs---� '4r. f�- ---------------- <br /> --------------- ------------------------ ------------------------------------------------------- --------------------------------------------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - - ---------------=----------------------------------------------- Owner <br /> BYE `max - - - --------- --- <: Title ��1�'��C�E��?t��'�r-..- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 7 f <br /> --= ---------------------- <br /> - <br /> - <br /> -BUILDING PERMIT ISSUED ------ --------------- <br /> ADDITIONAL <br /> ----------- - <br /> ADDITIONAL COMMENTS --------_-- - :�-- <br /> - <br /> - ------------------- ------------------ ------ ---------------------- - -------- ------ ----------------------------------------------------------- <br /> ----------- --- ------ ------- - <br /> - <br /> ------------ -------------------- ----- --- ---- -- -- - -- ----------------------------- <br /> Final Inspe Date --- - ----------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />