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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------- --------------------------- <br /> (Complete in Triplicate) Permit No. <br /> Date Issued 6_-_fn_2_0 <br /> --------------------------- -----_ -------_-------- This.Permit Expires 1 Year From Date Issued , <br /> I - ! J <br /> Applicatior0s 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.;Rvles and Regulations: <br /> JOB ADDRESS/LOCATION /-----_T SS¢- --- ` !_ 1 14�y----------........-------CENSUS TRACT --------- <br /> - ---- <br /> Owner's Name ---TT- ------ 1 1------•--•--------------------------------- --------------------Phone 8 ------. 4 <br /> Address <br /> city <br /> fTi---%----`---7 ---------------- <br /> Phone R <br /> 4_JContractor's Name _____ License ------------------ <br /> Installation <br /> p --installation <br /> will serve: Residence [Apartment House❑ Commercial ❑Trailer Court :',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ----------------`--------- <br /> - - ------------ <br /> Number of living units:_._------ Number of bedrooms -----Garbage Grinder ----— ----- Lot Size ___ ' ____//COf�� <br /> Water Supply: Public System and name ----------__ ----------------------------------------------------------Private <br /> Character`,of soil t6'a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ,❑ Clay Loam-0 - -- <br /> sr } Hardpan ❑ Adobe'❑ Fill Material ___ ---------If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must bbplaced on reverse side. <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted_ if public sewer is av lable within 200,feet,)`I <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ 5ize_7_X_____ <br /> -X Liquid De-fh _� <br /> � ♦nFi <br /> Q <br /> � i.Capacity/c:;?4C7------ Type No. Compartments ------------------•_-- <br /> 0 <br /> Distance to nearest: Wel[ ___ __________ _____Foundation ________✓_ Prop. Line <br /> 11I i . r".. <br /> LEACHING LINE [[No, of Lines ---.�----------------- Length of each line___Ak 'Tbfal Length _ ~ .----- <br /> I <br /> i et <br /> 'D' Box _M0.--- Type Filter Material �p<r_J-----Depth Filter Material -/Y------------------------------------- <br /> DIST ____ _______________________________Dis r ---------- <br /> SEEPAGE PITDe <br /> p ti: <br /> s - <br /> .� <br /> wti <br /> Distance to nearest. --------------- --------- ..----.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- D jttr___ _________.}_;_r________'_ } <br /> Septic Tank {Specify Requirements) -------- ---------------- ----------------------------------1 ----------- -- ---x--------'� ------ Q <br /> ---- <br /> Disposal Field (specify Requirements),'-' <br /> ri t_ <br /> i f <br /> I <br /> rs -' <br /> f <br /> ----------------- <br /> -------'- ----------------- --------------------------------------- <br /> 1 (Draw existing and required addition on reverse side) € <br /> I hereby certify thatI have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health Disirict. Home owner or licen- <br /> sed agents signature certifies the following <br /> 9 g ` <br /> "1 certify that in the perform, g ance,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:" ,. 3 <br /> Signed -- ----- - ----- --- - _ Owner �-Y�. <br /> BY -�--- ------------},'_'Titleip �T?C�i �✓ ' ---------- <br /> (if other than owner • `f it-:.I <br /> ,FOR DEPARTMENT USE ONLY] i <br /> APPLICATIONACCEPTEDACCEPTED - --- ----- -- - r 4 ------- ----' DATE .-- <br /> --------------- - <br /> BUILDING PERMIT ISSUED ---------------=� .. =.-------------------------------------------- ' DATE <br /> ADDITIONAL COMMENTS --- - --------------= = ------ ---- --------------- --------- - t'=- ----------- -------------------------=--------•--- --- --. <br /> -------------------- -- ------- - ------------------- - ---- -- ------------------- _ <br /> ---------= - <br /> -- <br /> Finallnspec _ ! M---------------.pate f <br /> ----- ---------- <br /> �,.,_ SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> E. H. 9 1-'68 Rev. 5M _ j..�.a.....�....- <br />