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FOR OFFICE USE: <- /,/`o / <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- J J0----------- IPW Permit No. <br /> (Complete in Triplicate) <br /> ---------------------------------------------------- rA <br /> TThi— Dcite-'DO - -= .� <br /> ______________________________________________T7 �'�' s Permit Expires��Year From DateJssued � Ji <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 CountX Ordinance No. 549 and existing Rule's ari&Regulations: <br /> JOB ADDRESS/LO TION ` d 3---- ------- ----------- -- -- --r------------- - ----------CENSUS TRACT //.... <br /> Owner's Na _ ! _ <br /> Address -P-- ------------ '�` � � -_ . City <br /> ///- •• y <br /> Contractor's Name ------------ -- ---------_-:--------License #I�Q.S�_�_-__- Phone 51*6 X_ <br /> fns Iationlll serve: Residence Apartment House❑ Commercial:❑Trailer Court i❑ <br /> IMotel ❑Other -------------------------------------------- <br /> Number i ing units:--- Number of edrooms _� _-Garb Grinder -_ Lot Size ----6. _ 1 E?-- <br /> 1--- f b------------- <br /> Water Supp�y: Public Syste and name _ ±,i F� ___ ._. _.-- -_ �_--_-----_- _ f Pri dte ❑ <br /> Character ofsoil to a depth of 3 feet: Sand 5ilt�❑ lay ❑ Peat❑ Sandy Loam ® Clay Loa 4' � <br /> Hardpan ❑ Adobe<, Fill Material ------------ If yes, type -------------- -----�: <br /> :1 <br /> (Plot plan, showing size of lot, location of system in relation to wells W6uildings, 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 [ SEPTIC TANK:[ I Size--------------------------------. - - Liquid Depth ------- <br /> Capacity -------------------- Type -------------------- Material---------------------- NoCompartments ------ ----------=-- r . <br /> 1 W <br /> Distance to nearest: Well ------------------------------------Foundation ------- -- -_.:--_ Prop. Line <br /> �. <br /> LEACHING LINE [ ] No. of Lines --__.-___ ___________ Length of each line_____.______ ____ _ .____ Total t*ength <br /> - - - - ---------------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth_"ter_Mgt6rial l�_�_ �-------.--__--__-_-_--------_._ <br /> _ t <br /> Distance 16"6earest~ Diameter beror`r`� "�--------------Property Line --------------------.--- <br /> SEEPAGE PIT [ ] Depth i --------------- � --------------- -.--__ _Rock-Filled Yes ❑ No 0 <br /> Water Table Depth -------------------------------------- -- Rock Size --------- --------- <br /> Distance <br /> =------------- i <br /> Distance to nearest: Well <br /> ------------------------- ---Foundation. ------------ 0---- Prop. Line <br /> REPAiR�AD.Q1g10N(Prev. Sanitation Permit _ --_-_y_ ___________ ___ Date. -- <br /> 4.4 <br /> j <br /> ( - C - +r_: <br /> i <br /> Septic Tank (Specify Requirements) ------------- - -- _ # - --- _ ,_-- -_ -- - ----- _ --- - ---_---- ; <br /> Disposal a (Specify Req ements -- -----G----- -- ----- ------ ---------- <br /> ---------------- <br /> --------- <br /> -----------''"' - ,Y------- -- ----- ---------- 3i---X-- ---`- ------------------------------- ------------------------- <br /> -------------------------------- ----------------I------------------------------------- <br /> ------ - - - <br /> - ------------ �t ------------------- -------------------------------------------------------------- <br /> (Draw existing and required additio E on reverse si-'fide) <br /> 1 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. SanJoaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: I <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 ----------------------- --- ------ -------------------------------------- Owner <br /> BYr------- , --- ------------------------------------- Title . ------- -- - ----------------------------------------------- <br /> (If of r an owner) f <br /> 4 W D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------0./1 DATE -- -, _" ----------------- <br /> BUILDING PERMIT ISSUED ---------- DATE -----------------� ------------------ <br /> ADDITIONAL COMMENTS - ----- •----------- <br /> --------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- <br /> Final Inspection by: -_-- - -- <br /> Date -- <br /> --- --- --------------- ----------- - - - - - - - --- =- =----�-�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. ? <br />