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FOR OFFICE USE: a (,�fH �/ <br /> v_ APPLICATION FOR SANITATION PERMIT <br /> ------------ -- F- Permit No. . /--"4_ � <br /> -(Com pyete in Triplicate) -- <br /> --------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued I�__� y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein I <br /> described. This application is made in compliance County Ordina ce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - ----------------------CENSUS TRACT ------------ ---------- <br /> Owner's Name ----------- 0------- -------- ------------------------------------------ Phone � <br /> -- - - <br /> -- - ------------ <br /> Address ----------- _ = City ^ <br /> ---------------------------License # <br /> nstall t onswill serve: � idece:�{•A artment House-E] Commercial Trail�r�t�! Phone ------------------------------ <br /> Installation <br /> ________________._._._______ <br /> Motel ❑ Other _1-__-______._ <br /> Number of living units:_____-_-- Number•of-bedrooms _____Garbage Grinder ------------ Lot Size ______T-- ______________ <br /> " I <br /> Water Supply: Public System and name --------------------- - -------------------------------------------Private <br /> 1 1. <br /> Character of soil to ri-dept1rof 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Ha dp6n ❑ Adobe E] Fill Material]_ ____ _ If yes, type ------------------------ <br /> a.. l r <br /> (Piot plan, showing-size of lat,4ocat-Q o�ystem-•in'relation to wells, buildings, etc. must be placed on reverse side.) qd, <br /> NEW INSTALLATION: (No septic Bink or seepage pitipermitted if public sewer'is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] ASEPTIC TANK;[ ] d Size---------------- --------- <br /> ----------- Liquid Depth -------------------------- <br /> i I , <br /> �acity __________.______-- Type -------------------- Materia ---------- No. Compartments <br /> 1istance to nearest: Well -_---°------------------------------Foundation ---------------------- Prop. Line --- _---------------- <br /> LEACHING LINE <br /> [l' No. of Lines ------------------------ Le'ngth'of'each'line------ -------------------- Total Length ------------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ------_--------_----- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ ) <br /> SEEPAGE PIT [ j Depth Diameter -----_-----------Number _:-_ _._ _ Rock Filled Yes ❑ No 0 <br /> Water Table Depth -----N------r--------------------------•--------Rock Size -------------------------------- t <br /> Distance to nearest.�l\--1 `-----------------------------Foundation -------------------- Prop. Line --------------- ------ <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------- Date _.- ----------._______----_) <br /> SepticTank (Sp cify Requirements)`--------------- --------------------------------------------------------------•------------------------ ------------------------------ <br /> Disposal Field Specify Requirements] ---- -- ------ `- ------------------•--------------- <br /> ----- - --- -- <br /> - - ' °1l----; 0------ r---------------------------------- <br /> ---------------------------- ----------------------F-- <br /> (Draw existing and required addition on, reverse side) <br /> I hereby certify that I have prepared this application,and Rth�at'the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations oaf 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 become subject to Workman's Compensation laws of California." <br /> Signed `sf T N Q --- A--- �- - -p �A -- Owner <br /> ---------------------- <br /> BY ---------------------------------------------------- -------- Title ----- --- ------------------------------------------------ <br /> []f <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 5 <br /> APPLICATION ACCEPTTq�BY - _ DATE �� -� o <br /> BUILDING PERMIT fSSUED- ' " ". ".�'" ""� " "- -DATE <br /> ---------------------------- ---- -- - --- --------------- <br /> ADDITIONAL COMMENT I r- - T-".. <br /> ------------------- - - -- -- ------------ ---- --- ----------------------------------------------- ----------•----•----------- <br /> ----------------------- k <br /> .. <br /> ( --------------------------------------------------------------------------------------------- <br /> _„_________________________________ L - <br /> Final Inspection bye _. --.Date ------Z0­7_2c0_- <br /> __ ____ _____F___ _ _ _____ __ _ _ _ _________________________________________.___-_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> t <br />