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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ® G <br /> fYZ- c� ---"---l.C�,`- ---------- �L Permitlo.f "4�l <br /> (Complete in Triplicate) _ <br /> -------------------------------------------------------- <br /> _________ This Permit Expires I Year From Date Issued Date 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 .----- �. _ 1___ iZ�t -- ��,?` -----/--'-Ci.-------CENSUS TRACT -----------------_--•---- <br /> Owner's Name Gl y -----y/-:r,------------------- Phone _ -��` � ' <br /> Address ----------------------` f '•��'u --- City --------.Q-r_7*3oC2--------- <br /> ---------------------- <br /> Contractor's Name --------5�----- -------------------------------- --- -------- --------------License # Phone - <br /> Installation will serve: Residence ❑Apartment House�❑ Commercial ❑Trailer Court ; <br /> Motel ❑ Other ------------------------------------------ <br /> Number of living units:---I------- Number of bedrooms -2------Garbage Grinder .-/-1 O.- 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 ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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 seepa pit permitted if public sewer is available within 200 feet,} <br /> e/ _� <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ size_ ��11r �_------------- Liquid Depth __-_ -��____.__. <br /> Capacity X4(2__,_- Type0zle"o - Mia ,'ve_e_ No. Compartments .------­!---------- <br /> .S r <br /> Distance to nearest: Well ___ ______.___..___.________Foundation _-___________________ Prop. Line .- ________...._.. <br /> LEACHING LINE [e*'No. of Lines -------I---- ---------- Length. of each line_---/,0( ------------ Total Length ------A_�--------- <br /> 'D' Box AveD----- Type Filter Materia#+ i 'Q Depth Filter Material -----—1'_-I I/_____________________________ <br /> Distance to nearest: Well ______ __ l__ Foundation -_--.-�--__-------- Property Line ....4s7/ _ <br /> r� <br /> SEEPAGE PIT [t.}/Depth - r Diametei$XY _____ Number .__--.__._�--------------- Rock Filled Yes No <br /> Water Table Depth ------------------------------------------------Rock Size ---------------------------- <br /> Distance to nearest: Well ----_.� -----------------------Foundation __- ------ Prop.Prop. Line ...S.i_______-.___.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------..-.----------) <br /> SepticTank (Specify Requirements) ------------------- ---------------------------------------------------------- ---------------------,..----------------•---------- <br /> Disposal Field (Specify Requirements) ---------------------------•--------------------------------------------- ---------------------------------•--------------- <br /> -- ----------- --------------- ------- - / ---------------------- --------- -- -. - <br /> ----------------------- --------------- - ` -----fit` < -- �� -------------------- <br /> (Draw existing anred uired addition on reverse side) <br /> N <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. Home owner 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, 1 shall not employ any person in such manner <br /> as to beco u Iect Workm 's Compensation laws of California."_ <br /> Signed --- - -- -------------------------------- Owner <br /> BY - -------------------------------------------- 7itle --------------------------------- ----------------------- <br /> (If other than ow 0 <br /> OR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..---- ..- . _ - _.------ -- -------- DATE --------r0---- r ------- <br /> BUILDING PERMIT ISSUED _--------------------------- DTE ------------------- ---------------------- <br /> ADD] <br /> - <br /> ADDIJON�AL COMMENTS ------ <br /> -------------------- <br /> -- <br /> -- <br /> ----------- ---------- - <br /> ----------------------------------- �^ ---------------- ----- --------------------- ------...-------------------------------------------------- ---- ------- <br /> Final Inspection by; ( ---- ------------------------------------------ Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />