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FOR OFFICE USE:` - <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------- <br /> (Complete in Triplicate) Permit No. �-- <br /> --------------------------------- VN I , <br /> 7:a_.._.._'.________.._ 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 made incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - `_f__-- �/� "_�� r_-tt' ------------------------------CENSUS TRACT ---6-h------_--- <br /> Owner's Name f}/-`�------------------------------------------ -------------------Phone�.�7"_�:�_I.�_.-. <br /> Address ---`�, .L"_ 37 .�• �9/lc'fZ',V7_24!`� Cit /�l,�•�T�cA- <br /> 1..---- --- ---------- -------- -------------------- . Y <br /> Contractor's Name X /!'_-_SEf'T�'____ i ' 5_______________________License - - e-_._ Phonecg- -�" E'-�-- <br /> Installation will serve: Residence [A- artment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑Other <br /> Number of living units:--5;k---- Number of bedrooms --.---Garbage Grinder x'V�'___ Lot Size <br /> Water Supply: Public System and name ---------------------------------•--------------------------------•--------------------------------------------Private [l <br /> Character of soil to a depth of 3 feet: Sand'�ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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,) O <br /> / -i ` <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ Size_ 1p -_ <br /> ---X �/_"_------------ <br /> . Liquid Depth -6-1---------------­ P <br /> Capacity L ------- TYPeVW_ C4S)7...__ MaterialNo. Compartments ...�............... O <br /> Distance to nearest: Well _-------------______Foundation -1C-__-.-.__._._- Prop. Line . _. ....._._.._ <br /> i <br /> LEACHING LINE [ No. of Lines __ -- Length of each line_/ -- Total Length -3-0-0............... <br /> 'D' Box Type Filter Material 4C --------Depth Filter Material ___._----------- ------------- <br /> Distance to nearest: Well .. ........... Foundation ---------- Property Line ............ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ----------- ---- Number ---------------------------- Rock Filled Yes ❑ No 0 <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 /> -----—----------------------------------------------- ------------------------------------------------------------- ---------------------------------------------------------------------------------iq <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 /> By ------- -----= --------------------------- Title __ i9.t°.ri-✓FiQ-- <br /> ✓E -- ------ --- -- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY q <br /> APPLICATION ACCEPTED BY _. 1.R-'Q-------pop----------- ---------- --------- ---------------------- DATE _77_ ..-'_- _ ------------ <br /> BUILDING PERMIT ISSUED -------------------------- DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------------------------------------------------------------------------------------- ---------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- --------------- <br /> ------------------------------------- <br /> - - - - --------------------- - <br /> Final Inspection by. <br /> -'--- - Date '�`ZS" �{ --------•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />