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t <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> \ Permit No. <br /> (Complete in Triplicate) <br /> - - - \ <br /> O <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued -- ----- .1 <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 /> JOB ADDRESS/LOCATION ._15i-6_ __�_______5c____R_1_I�_P�_F�T____________M_1TC.�-___.__.__CENSUS TRACT .._��'......... <br /> Owner's Name Phones3-_70s-3----- <br /> _�"12 ------------------------------------.-------- <br /> Address --- awx------. City ---�19fV_jpxz0q------------------ ------------ <br /> Contractor's Name �..;�, _ _/�"'Q--------------------------_License#2�s�/-fa'— Phone ------------ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__-- ------ Number of bedrooms -�--_-Garbage Grinder ------------ Lot Size _________ - ------------ <br /> Water Supply: Public System and name ---------------------------------•-----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'X Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _Na_ 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 seepa it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[,Or Size__x_9______ ..3__X__q------ -------- Liquid Depth __ ......>_ <br /> Capacity aWOp___,__ Type Material&_" ._ No. Compartments ....... -... <br /> stance to nearest: Well ____ _______________.-------Foundatio� D___________ Prop. Line 6____ <br /> LEACHING LINE [ No. of Lines -----X___________ Length of each line______lao___________ Total Length ---.......................... <br /> __ � <br /> 'D' Box ---o------ Type Filter Material jnn�d-k------Depth Filter Material __ _ ___________________________________ <br /> Distance to nearest: Well __ _d_________ Foundation ----/_-&�----------- Property Line S6---_-_..___-.-.-_- <br /> SEEPAGE PIT [ ] Depth _________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•--------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ____________ __________ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to becom subject to Work n's Compensation laws of California." <br /> Signed ----- - -----------------/-------------------------------a0------------ <br /> Owner <br /> -- _ -- - Title ------------------_------------------------------------------------- <br /> (If at he than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- __ _ -----------fL-_ k_ ------------------------------------- DATE --- r-_ -f�. Y-----_-- <br /> BUILDINGPERMIT ISSUED -----------------------------------------------------------------------------------------------------DATE ------------- ----------- --------------- <br /> ADDITIONALCOMMENTS ----- ------------------------------------------- -------------------------------- --- <br /> ------------------------------------- -;� ------------- ---- ----- -- - ---------------------------- ---------- --------------------------------------- --------- -------- <br /> -------------------------------- - -------- <br /> ------------------------------------- - --- -- - - <br /> Final Inspection b `--------------------------------------Date --- -I ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />