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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />..................................... ......... ....... Permit No. .7- <br /> f. <br /> (Complete in Triplicate) ..­/_�.W- <br /> Date Issued <br />.......................................................... This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit <br /> mit 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/LOCAT ON .... ...... . ...... ...CENSUS TRACT .,-........__........ <br /> Ph .... <br /> ........... City ............................ <br /> Owner's Name ....I.... .. ......... .. <br /> XZ4Address ........... �:_02_ 24 <br /> ------------ <br /> Contractor's Name --- License # Phone 492.1"JZ941 <br /> Installation will serve: ResidenceApartment House 0 Commerciol :E]Traller Court 0 <br /> A <br /> Motel n Other ........... ............. .................. <br /> Number of living units:._ /_ Number' of b rooms. -...._..GarbageCK1110 ---- Lot Size <br /> er ......... <br /> ----------- .................. Private 0 <br /> .. .... ...... <br /> Water Supply: Public System and name ... ................. ........... <br /> Character of soil to a depth of 3 feet. Sand ❑ Slit E] Clay 0 Peat 0 Sandy Loom {3 Cloy Loom 0 <br /> Hardpan ❑ Adobe Jk Fill Material =...-------- If yes,type ---------------- ------ <br /> Plot plan, showing size of lot, loco 11on of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW7ktf_k_LCAT49N: (No septic tank, or seepage pit&permittvilyublic sewer is available within 200 feet,) <br /> (PACKAGE TREATMENT SEPTIC <br /> TANK -S7'?i'z e........................... .................... Liq^uid Depth ....................... <br /> Capacity .................... Type .................... Material--------------------.. No. Compartments -----_----_----_ <br /> Distance to nell1w; f ......................oundation Prop. Line ...................._.t,/ <br /> Z,-),< es I ........ ........ ----------- <br /> LEACHING LINE NO. of Lines ------------ .......... Length of each line....__.._____. ... Total Length <br /> 'D' Box ............ Ty-pe- Filter Material --------------------Depth Filter Material ............................................ <br /> Distance to nearest. Well ........................ foundation ........................ Property Line ........................ <br /> SEiPAGE PIT ------ ... <br /> epth a-w`r4e. ....... Diameter ........ Number .....4 1.— c Filled Yesek No C] <br /> oter Table Depth .�..... .e........... ize .... e. <br /> .9 <br /> Distance to nearest: 1V(Il ..../1 ,f C F o I Drop. Line _4 ........ <br /> 1V( <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...w�....... ...................... Date .................................. <br /> Septic Tank (Specify Requirements) .................... . ...............jr�.. ...... <br /> -------------------------------------------- r ........... <br /> Disposal Field (Specify Requirements) --------- - ----- - - - ---------- <br /> ----------- <br /> . ......... . .. ........... <br /> ­V-1e;i.................. ------------------------------- <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, Slate 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 Workman's Compensation laws of California." <br /> Signed --- <br /> ---------------------------- .... .............................. Owner <br /> By .... 721- . ........... ------------ ------- -6 �al 144--------- ........... <br /> ------ Title <br /> (if other than--o—Vvner) <br /> 4 FOR AnRTMENT USE ONLY 4— <br /> APPLICATION ACCEPTED ........ .................. DATE ...... <br /> BUILDINGPERMIT ISSUED ..------ .................................... ......... .............................................DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------I........I......___---—-----------------------I.................I--------------- <br /> ........................................................................................................................I........ . <br /> ............................ ............ ................................... <br /> ......................................... . . . .. ....... .............................. ................ <br /> .. .............................. <br /> ....... ... .... --- -------- ---- ..... ...... <br /> ...............*... ....... , -------- <br /> ---- ------ ------ ...... . ........*........ <br /> Final Inspection by: ............ ...... .. .............. . ...... — ... .... ..................Date .... ......;4 ... <br /> SAN JOAQUIN.-L AL HEALTH DISTRICT <br /> E 13 24 7/7232%1 � <br /> E. H. 1.'68 Rev. 5M <br />