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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT. q <br /> ---------------------------------- <br /> - --- Permit No. 771-.�_`�_�� <br /> ----- ------ --- <br /> (Complete in Triplicate) <br /> -------------- U q <br /> ---------------_-------------------------________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued .-IP-_�_1_:7/ <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 .___.__ _Q, D___(__---.r_��Q�_��K,�-___:.l�h _---.._._-:-_._._--_---CENSUS TRACT <br /> Owner's Name -----( - �_Q�----6- -f1 ------------------------------ --- ---Phone __.--------------------------- <br /> Address ----20-1-al......... ------A_1_R_�®_R^�------------------------------ City --.,.. 86/.1/__7ZF ?!k--------------- -------------------•------ <br /> �y�'1 / L�^<�/' <br /> Contractor's Name --'-/� - ------ ---- --- ----- ---------------------------------------License # ---------:-------------- Phone -----------••------•---------- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <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❑ Silt❑ Clay ❑ Peat❑�� // Sandy Loam El. Clay Loam <br /> Hardpan E] Adobe E] Fill Material -Affi---- 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.) 0 <br /> NEW INSTALLATION: (No septic tank or seeps it permitted if public sewer is available within 200 feet,) / t, �' <br /> i� <br /> 114 i � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size__`�_--G___�s.1 4,_ __-.J- ..-__ Liquid Depth ---- ---- --------- <br /> Capacity _A*45------ Type PAD-E 42aterial---------------------- No. Compartments <br /> stance to nearest: Well ----15 0--___________.__._-._Foundation ----------- Prop. Line ........ <br /> LEACHING LINE No. of Lines -_-_ ----__--_--- Length of each line------gro___ _________ Total Length , _sir ........... <br /> 'D' Box ----/----- Type Filter Material Depth Filter Material -----le <br /> --i <br /> 40* <br /> Distance to nearest: Well __-�Q__-_______-_ Foundation __-0:----------- Property Line __s.3 ff__ _........ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter - -------_--- Number ----------------- ---------- Rock Filled Yes ❑ No i❑ <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) ---------------------------------------------------------------------------------- ------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ____________ ------ <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. Homeowner 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 subject to Workman's Compensation laws of California." <br /> Signed ---- - --- --- -- -- --------.� S------------------------------------ Owner <br /> By --- --- - -- -- --- ---- -- ------------------------------------------- Title --------------------------------------------- ------------------------- <br /> her t an owner) <br /> ...�--� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---___t_._t.ra tTR�O----------------------------------------------------------------------------_____________. DATE ----- <br /> BUILDING PERMIT ISSUED ------------------ -- DATE ------------------------------ ----------- <br /> ADDITIONAL COMMENTS �1'� ---K -D Lac/ I-- -. <br /> -------------------------------------- ----------- -- ---------------------- -- ---- -------- -- --- - -------------------------------------------------------------------------------- <br /> ------------------------------------- ---------- - -- -- - ---- ------------------- --------------------------- - - <br /> -- = ---------------------- <br /> --- > <br /> Final In <br /> 1�� ----------- -- --• - Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />