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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. . <br /> Date Issued -...- <br /> ..-This Permit Ex Ires I Year from Date Issued <br /> .3.=7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> describ3d.ospplica is made in compliance with County Ordinance No. 5:49 and existing.Rules and Regulations:' <br /> JOB-ADDRESS/LOC N .-•I�.--- r �- :-r ... CENSUS TRACT .k-& ...._.. <br /> _... <br /> Owner's Name .................................................... .................................Phone ----------------------------------- <br /> Address -...... �- _ ...... ............... .,.._...- - ... City ._.- ............................................. <br /> Contractor's Name [7 * _-.. ,OA ..�[. ..�......:........Ucenso # jO._.-.....- �...._.. <br /> Installation will serve: Residence 0 Apartment House fl Commercial❑Traller Court 0 <br /> Motel ❑Other <br /> Number of living units:............ Number of bedrooms ----L.'.-Garbage.Grinder ......_._ Lot Size ---:--------------......................... <br /> .. <br /> Water Supply: Public System and name ...Private,. <br /> Character of soil to a depth of 3 feet: Sand b Shit❑ Clay ❑ Peat❑ Sandy Loam Clay Loam Q !�! <br /> Hardpan 0 Adobe 0 Fill Material ............ If yes,type................ _-..-. <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 diinilable within 200 feet;l ��// <br /> f �� . , <br /> PACKAGE TREATMENT { SEPTIC TANK ze..._.. �. Q. ............:l:.......: Liquid Depth .... .._ ...---•:__.... ' <br /> Capacity 1 .�a _ Type - i -mmiaterial No. r,,Compartments .. ............. <br /> a � <br /> ' 00 <br /> j . Distance,to nearest: Well 0 __•....k..............Foundation .... Prop. Line <br /> LEACHING LINE No. of Lines ...� _..•---._..: Ler<gth of each line....__- .....:.._. Total Lenfth ...�.... . ............. <br /> D. Box __.. -.-._. Type Fi#ter Material Depth .Filter Material ..f.�. ...................................... <br /> Distance to nearest: Wel! ... ...--> ..-_ Foundation ...................:.... Property Line P., .... # <br /> SEEPAGE PIT Depth .--._-_. Diameter . Numb r TM Rock Filled Yes 'Nor <br /> E <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) -------------------------------------- .... .................... ....... --•••-----•-••---- I........................ <br /> Disposal Field (Specify Requirements) ........... --•-- ._._..::•• - .[........:......... .........................•............ <br /> - <br /> --------------------------------- ............... ------------------------ ......................................... --------- -------------------- ........................ <br /> -------------­-----­ •------------------------- ----- <br /> IDrow existing and required addition on reverse side) k✓ <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 Heall&District. Home owner or Ileen- <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 mangier <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed�4yf <br /> ....-. ---•-• Owner <br /> ------ <br /> By - . 4...0�--� ���..__._. Yitle 4�1:Ctrtl>0!�................................ � <br /> otherthan owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -- ---- ---- - ---------------.:- - -------------- DATE -- <br /> BUILDING PERMIT ISSUED ........... --------- DATE <br /> ------•- <br /> ADDITIONAL COMMENTS -------•------ •--------------------=-----•-•--------•------- -------------......... <br /> ....................---------------................---------------.......... <br /> - -- ----- -----•-----� --- -- <br /> ------------------------- -------- _ <br /> :---•--------- ------- -.. <br /> -•----------------------------------•-•-••- ---- <br /> Final Inspection by: .........r ! - `'✓' 't =..-- Date - -� -+ ' - <br /> EH 13 24 1_68 Re's'• 5 SAN JOAQUIN -LOCAL HEALTH DISTRICT 8/74 3M + <br /> - � i� <br />