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FOR OFFICE US , <br /> f�av APPLICATION FOR SANITATION PERMIT <br /> -1"� �.7Q.----------• -- ------ Permit No. ��----�---- <br /> {Complete in Triplicate) <br /> ---------------------------------------- /- 6 -7d <br /> This Permit Expires 1 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-7_$--=/.;._� ___---------�eC `�� --f7-----��. ----------------CENSUS TRACT ------- <br /> l7 'i <br /> Owner's Name - _-/ _�,t' .--�/.. ..45--------------- -- ----------------------------------------------- ------Phone <br /> Address ------ <br /> -- -- ----- ------ - C'&Y- r--------------------------------------- <br /> Contractor's Name ----- .-- -f1 -' A?,­re7zy ---------, �---.License #;� _�_ Phone <br /> Installation will serve: Residence[XApartment House'-E':] Co mercial ❑Trailerft oyrt <br /> Motel ❑ Other ------------ -------------- <br /> Number <br /> -----------Number of living units:.-.-/---- Number of bedrooms _.f------Garbage Grinder !_pt Size -------------- <br /> Water <br /> -------------- <br /> Water Supply: Public System and'name ---------------------- --------------------------------------- "=_--- - ---------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay E] Peat ❑ Sandy L a n ❑ 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.} f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer;Is available within 200 feet,) <br /> PACKAGE TREATMENT 'CapacityP71CTANK:[ I Size-------------------------�_`_-------------------_ Liquid Depth ----------------•--------- <br /> ---- -------- - ----- Type -------------------- Material--------- ------ No. Compartments ------ .-.... <br /> Distance,to nearest: Well ------------------------------------Foundation -----.-----------------Prop. Line --------------__--_--_ <br /> LEACHING LINE [ I No. of Lines ------------------------ Length of each line----------w---------------- Total Length ___-_--_- <br /> 'D' .Box ------------ Type Filter Material --------------------Depth:Filter Material --------------------.-------_............... <br /> Distance to nearest: Well - -------------- Foundation ---- --------------- Property Line ---------............... <br /> SEEPAGE PIT 'Depth _ _ _ <br /> - Diameter -- --_- _ ___ Number ------------ --------------- Rock, Filled Yes C3 No Cl <br /> WaterT <br /> ' <br /> P ]„able Depth ---------------------------- <br /> -------- ---------Rock Size ::.----------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundations-------------_------ Prop. Line ----.------.---- <br /> tc , <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------- <br /> _ Date -----=-----=--------------- 1 <br /> ------------------------------ ------- <br /> Septic Tank (Specify Requirements) ---------------------- ------------------------------------------------------ -------------------------- <br /> Disposal <br /> '------------------------Dis osal Field (SpeVy Re uirbments) <br /> � ----------- <br /> ------ -------------------------------------- --- -----I----------------------------------------------------------------------------------------k--------------------------------------------------------- <br /> (Draw <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 fpIlciIng: <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 Compens • n laws of California." . <br /> Signed --------- ----------------- ---- ----------'---------------- ---- ----- ------ Owner <br /> BY -------------- ------------- --- ----------------- / �: <br /> y <br /> (If oth an owner) 4 t, ;i,` aF <br /> FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY ----- ---- ------------------------------------------------- --- ----------------------- DATE i i'=� a--------------------- <br /> &111LDING PERMIT ISSUED =---------- --DATE .1•----------------------------- <br /> ADDITIONAL COMMENTS ---- -- . <br /> 1 <br /> --'--`- ----- -------------------- ---------------------- •t <br /> ------- <br /> ----- --------------------- _ <br /> ------ <br /> ----------------------- { <br /> Final Inspection by. -- -- -------------------------------------------------------------- ------ -------------Date1 - -o-- ---------- <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> E. H. 9 1-'68 Rev. 5M v i - ` �� ` `' �, -." � � �' �.' `' <br />