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NO <br /> FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> - - --------------------------------------------------- Permit No. <br /> ---------- ----- <br /> -------------------- (Complete in Triplicate) <br /> a Date Issued ./Q_:_?iP:_7_ <br /> -----_-_----------------_-_---------------------_- __ This Permit Expires 1 Year From Date Issued <br /> t: it LC a 5 c� a' ... 1 <br /> Application is�ereby made to the San Joaquin Local Health Ristrict fora permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 <br /> - I--` - ---- andeWR�Il <br /> and Regulations: <br /> JOB ADDRESS/LOCATION ] -- - ��ef; 1F5Vf_ C �) � ---- - ENSUS <br /> TRACT -------------------------- <br /> Owner's NameJAW/JV IVIL A------------------------------------------- -------------- �-------------------Phone --------------------------•--•------ <br /> Address .Pln -----------------=---------- --------------------------------- City � �� - -- <br /> ` *-- <br /> Contractor's Name _: � � --- -----------------------------------License # 2S-J;y?_�y- Phone ,�_T /... <br /> k <br /> Installation will serve: Residence @TXpartment House❑ Commercial'❑Trailer Court l❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size , �- __:__--_________- <br /> Water Supply: Public System and name ------------ - - ------------------------------- - --------------------------------------- _____.-Private <br /> (� No <br /> Character of soil to a depth of 3 feet: Sand,0 Silt F] Clay E] Peat E] Sandy Loam El Clay,Loam❑ .Q <br /> Hardpan ❑ Adobe '[Fill Material __________ If yes, type ___________________________ Dj <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 available within 200 feet,) ` <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size_./ _: _ _ ------------------ Liquid Depth ___ YY--------- <br /> Capacity/004-1-4---------- Type --------------------- Material --- No. Compartments --- '-----....... <br /> Distance to nearest: Well ____'� --------------Foundation _-_-_______ Prop. Line <br /> LEACHING LINE [.] No. of Lines _______ __________ Length of each line____ ------ ------ Total Length ___r� -- ------- <br /> ._.__ <br /> 'D' Boxronearest: <br /> _ Type Filter Material 'J_� Depth Filter Material ----------�_�_____________-- .___-_ <br /> ' Distance Well __s0�0�------------ Foundation -----/A------------ Property Line ----.J_______________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No l❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br />'� Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------- ----------------------------- -- <br /> ----------------------------•----------------------------------- --------------------------- <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------- ----------------------------------------------------------- <br /> ------------------------------------------------------------------------------------- ------------------------------------------------------------- -----------------------•------------------------ <br /> --------------------------------------------------- ------------------------------------------ --------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <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, I shall not employ any person in such manner <br /> as to become subject to Workm n's Compensa ' n laws of California." <br /> Signed ....... -----------------------40- Owner <br /> BY ------------------ ---- - - - ------------------------------- Title . ---- ------------------------------- - ------------------------- 1 <br /> (If other than owner) <br /> FOR DEPART ji NL <br /> APPLICATION ACCEPTED BY --- ;` - -------- DATE ! ----------•------- <br /> BUILDING PERMIT ISSUED ---------- DATE ------------- ------------------------ <br /> ADDITIONAL COMMENTS ---------------- ----- �� �t r ------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- --------------------------------------------------------------- <br /> __..__ ____..___.._ _ __________._____________ _ Y_-__________________________ <br /> Final Inspection by: ----------------------------------------------------------------------------- ---- - � - - -----.Date ----IV-IS-2 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> q' E. H. 9 1-'68 Rev. 5M C" 1`J <br />