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FOR OFFICE USE: <br /> ' -•. ,-T;. <br /> ---------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. - /10 <br /> 7/3 <br /> (Complete in Triplicate) <br /> ----------------------------------------------------r--- h <br /> --- <br /> _________ _________ _____ This Permit Expires 1 Year From Date Issued <br /> ------ ---- <br /> Date Issued --q <br /> t <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. 5499 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION !: _ pQ---: -> © 1- - rl---------- 1 �- (_-CENSUS TRACT _---- ----- <br /> Owner's Name <br /> � � t, <br /> ---------------------------------------------Phone ------------------ --•-------------- <br /> 1- - 1 - '-.-- .- -- uR! -------fes � �w -----_ -------- Cit <br /> Address - - --- - -- - r- - - Y ---------------------•----------------------------- <br /> Contractor's Name _.-.Mkb�4V_P,--:--- ---------------------------License # ---------:-------------- Phone ----------••--•-------------_ E <br /> Installation will serve: Residence partment House❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑Other ----- -------------------------------------- <br /> Number <br /> ------------------- ----------------Number of living units:--------- __-- Number of bedrooms -__ arbage Grinder ---Ad__ Lot Size -- - --------- ----- ------•• <br /> Water Supply: Public Systeand name ------------ ---••--------------------------------'= Private <br /> Character of soil to a dep th of 3 feet: Sand' Silt fl Clay,❑ Peat- ___Sandy Loam ©., ' CId,.'ibam;❑— - •- --j <br /> Hardpan E] AdobAdobe-[] Fill Material _ If yes, type._."-•__.:>>------------ <br /> (Plot plan, showing size of lot, location of system inrelation to wells- lLuildings, tits must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit peLr."'itedii p blit sewer is available within 200 feet,) (jay I <br /> PACKAGE TREATMENT [ ]; SEPTICTANKf ] i, `Size---------------------------- ;----,---- Liquid Depth ---------------------.•---- <br /> Capacity -------------------- iType .........k...... -= Material Foundation , No. Compartments ---------------------- 9` <br /> Distance to nearest: Well ------- - - i i Prop. Line <br /> I r,. .-_s . a.i <br /> LEACHING LINE [ ] No. of Lines --------------i--------- Len; th f each line-_----------------1-----�-_ tal Length _-_-_----__---_. -_-__-_-- <br /> 'D' Box -_--_______ Type Filter—Mate ial ......................Depth Filteri Mater al -------------------------------------- <br /> Distance to nearest-\Wbli t__ ______ ___________`Foundation ------------------1---_- Property Line, ____-_---_---_-_-_--_--- <br /> It <br /> t <br /> SEEPAGE PIT De th -----l---_De--th Diameter ---__ _____ NUm�Roc ize -_-_ -- Rock Filled Yes ❑ No <br /> [ ] P <br /> Water Table p <br /> -Distance to nearest:-Well - --- --- ------------------------Foundaation -----I-- -_----- Prop. Line ---------.------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------ -_-__. - ----------------------- Date __-_----.-.___----:_-_- __.f-_--_-) ' <br /> Septic Tank (Specify Requirements) �! ` ` 4 ---- <br /> - j.. ---- <br /> Dis ---- <br /> Disposal Field (Specify Requirements) � /�-D -(' '�i7_£tf2--___�1N� —__�_1>[5 P4__�C--:,--------7_L�--------�F----��-------- <br /> -------- ---- <br /> p Y q w <br /> [ � <br /> --------------------------------------------------- <br /> -------------------------------------------------------------------- t------14 :4-----------------------— ------ ----------.-_-__--__--- <br /> (Draw exi,st,ng!and required addition on reverse side) i1Y <br /> I hereby certify that I have prepared thisiapplicatfiian and that the work will be done; insaccordance with San Joaquin <br /> County Ordinances, State haws, and Rules and 1Regulations of the-San.-��oaq�n Local HealtFi District. Home owner or licen- <br /> � .� <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 ------------------------ - --------------------------i-------------------- ------------------ Owner , <br /> BY --------------------------- - '; ----- --------------------------- -- Title ----------------------------i----- -- ---------------------------------- <br /> (If other than owner) <br /> --FOR—DEPARTMENT- -USE—ONLY <br /> APPLICATION ACCEPTED BY t '-R �----- ---------- �� --- -------• DATE ` '= �f '------- <br /> BUILDIInyPERMIT"ISSULD�'--�------- ----- ^._------------------------------------------------------� DATE ---------------------------------------. , '._-- <br /> ADDITIONALCOMMENTS ----- -------- -- --------------•--------------------- ---- ----------------------------------------------------------------=--------------------------- <br /> - ---------=-- ----------------------- ---- --------------------------------------------------- - ----------I--------- - - <br /> ------- ---•`fie--- ----- - - --- - -- -- ------ ------ -- - --- -------------------- ----------- �- f _ <br /> Final n ' -- ------ <br /> - <br /> ---` ---- - - -- -- - --------- -----------.Date -- ------- --- ------ --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s ' <br /> E. H. 9 1-'68 Rev. 5M <br />