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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------- ------------------------ --------- <br /> - <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------- <br /> Date Issued 72Z <br /> Z <br /> Z2C S- Sr ✓Tr`{ This Permit Expires 1 Year From Date Issued 2s' —o& —t <br /> Application is hereby made to the/San Joaquin Local Health District for a per to c stall the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and e d Regulations. <br /> ._sio� �; ". �-----�- <br /> JOB ADDRESS/LOCATION �- <br /> �___-�CENSUS <br /> Owner's Name c'J:--------�©__S�s-16e ----------------------- ---------------- ------------ - ----- one --------------------•--------------- <br /> Cit <br /> Address f__ ._- s 1. l+rl. bY � ---------------•--------- .-- <br /> H�O4'0-tr <br /> Contractor's Name .- .@-T�� _J cJ ' ---------.License # 5- /Z_T __ Phone ------ ----•--•------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ---------------------------------------- <br /> Number of living units:....[_...... Number of bedrooms -�-----Garbage Grinder ------------ Lot Size -0------ <br /> Water Supply: Public System and name �'----- -------------------------------------------_-------------------------------------_Private F]Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> - <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size--------jo...5_p� � <br /> ---------------------- Liquid Depth --- _� ------ <br /> P ty YP P ��------•-- <br /> 1 <br /> Capacity 1_4P------ -- Type ---- -�-�' titerial---_�es�- lo. Compartments -- <br /> Distance to nearest: Well _ _____________Foundation __/©___________ Prop. Line _ ______-_--__ <br /> LEACHING LINE [ ] No. of Lines ------- ---------- Length of egch line------------ Total Length ----/A2._________-- <br /> 'D' Box env_____ Type Filter Material - !.---Depth Filter Material -----_f --______________________________ <br /> Distance to nearest: Well --------- Foundation -/Q_______________ Property Line _.__-_____ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number -----------.---------------- Rock Filled Yes F] No ❑ V <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------------- ------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements] ------------------- --------------------------------------------------------- --------------------------------------------------------- <br /> DisposalField (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 becompeli2ibiect to Workman's Compensation laws of California." <br /> Signed ----- � - - - ------- <br /> ` -------- ---------------- Owner <br /> - 2 <br /> BY --- - - -- %-- = Title --J - ' <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> e ------------------------------------- <br /> BUILDING <br /> --------- ----2--------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------- ----------------- ---------------------------------------- --------------------------------=--------------- ----------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------z�--------------- ----------------------- ---------------------------- --------------------------------------------------- <br /> --------------------------------- -- ---- ----� <br /> ------ <br /> - ------------------------------------ ---------------- -- -- <br /> Final Inspection b ---- -------------------------------------------- <br /> -- <br /> -- -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M `-r <br />