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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> - --------------------------*�------- <br /> Dat Issued .-��-� �'. <br /> -------- --------------- X This Permit Expires i Year From bate 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' <br /> JOB ADDRESS/LOCATION - � c � --- <br /> ---- -� --- - t <br /> _ - -----CENSUS TRACT ---- <br /> Phone : rG -Owner's Name -------� 4------A?, ���------------------ ----- -• - <br /> Address ------- � .1 ��17G � ��%-'�,--------: II <br /> I <br /> -City ,f�l.��/__��`�-�----------------------------------------- <br /> Contractor's Name d� '�"=-- "'_...------.License ��� �:: PhoneZU-7 ��; <br /> Installation will serve: Residence [ partment House❑ Commercial :❑Trailer Court ;❑ 1 <br /> A. § ---Motel ❑�Othet -------------------------------------------- ] <br /> Number oflivingunits:---1T__._ Number of: bedrooms 3-------Garbage Grinder �_-___ Lot Size __ ____ -- ----- <br /> 134 <br /> Water Supply: PublicSystem and name -------------------i-------------••------------------------------ -------------- '----------•-- .. Private <br /> Character of soil to a•depth of 3 feet: Sand'[ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam_❑ k <br /> ! Hardpan Fj Adobe'0—Fill Material _.-_-_.-4f yes,-type-__,_ _____--------------- <br /> ( <br /> (plot plan, showingsiie 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,) <br /> rNT� C 7 SEPTIC TANK Size-------------------•-•------------------ - Liquid Depth -------------_---=------ <br /> N - <br /> s <br /> PACKAGE TREATMENT i Capacity -----------'`_----- Type -------------------- Material--------------.------- No. Compartments ------ -------- <br /> � Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. line ---------------------- ' <br /> LEACHING LINE No. of Lines --------I------------- Length of each line--- Total Length .�.�-------.,..•••-- <br /> . f <br /> ` DBox _ Type Filter Materiral �' r-______Depth Filter Material _fe 1 <br /> 1 r . <br /> ! Di.stance to nearest: Well __� _____________ Foundation -- Q__________--- Property Line______________-_.___ i <br /> SEEPAGE PIT [ ] € ) Depth _.-_-- - Diameter - -------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> I Water Table Depth ------------------------------------------------Rock Size ---------------------------•--- <br /> �fvDistance to nearest: Well ----------------------------------------Foundation -------------------- Prop• Line _-____.__. _�a___-' <br /> REPAIR/ADDITION( ,re . ---------------------------------- <br /> Septic <br /> Sanitation Permit C# -------------------------------------------- Date ---------------------------------- <br /> Septic Tank (SpecrfyiRequirements) ----------=--------------------_. ------------------------------------------------sem -------- -- -----�s <br /> Disposal Field (S iecify-Requirements)- - � ' 7 i '' --------- <br /> --,,4,A V-.4 �_ _- J�.A a ► / ..�. ti ------� --- --- - = r w <br /> (Draw existing and required addition on reverse side) �•-' <br /> I hereby certify thalAlhave prepared this application and that the work will be done in accordance with San Joaquin t <br /> County Ordinances"State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or )item- } <br /> sed agents signatu ceki flies the following: <br /> "I certify that in tl a performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be m sub{ec to Wo kma ompensation laws of California." <br /> Signedta --------------------- -------- Owner _ <br /> B " \i`-'------ Title Q / <br /> Y ; 4 f ------------ <br /> 1( <br /> 1( other than owner) �. --- S , <br /> �s FOR DEPARTMENT USE ONLY am 1 <br /> APPLICATION ACCEPTED BY --------------- <br /> BUILDING <br /> BUILDING PERMIT ISSUED -------------- --------------------- ------------------------------------------------- ---------------DATE ------------ -------- <br /> M <br /> ------- <br /> ADDITIONAL COMMENTS x - <br /> -------------------------- ------------------- ------- -"I <br /> ----------------------------------------- ----- ------------------------ - -- - - - -- ------------------------------------------------------------------------- # <br /> -- ----------------------------------------------------------- g <br /> ------- <br /> -------- <br /> ------ ---------- ----------- - --- -- / <br /> Final Ins b Mei f-4�-- --------------------------------Date ----- <br /> SAN <br /> ---SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Li 1�- <br /> F H 9 1.'68 Rev_ SM <br />