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FOR OFFICE USE: <br /> w APPLICATION FOR SANITATION PERMIT <br /> ..__....._.. jj <br /> 4Complete in Triplicate) Permit No. ..7�/—_& •_ <br /> " ............ . This Permit Expires 1 Year From Date Issued bate issued ..��•�3d;�y <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. 544 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name � ,.,.- -;�.;4;;�;,�.;,.- -••••...............CENSLI5 TRACT ._.....:....... ....... <br /> .-- .......I... <br /> Address ,�_. a..�...5 ne ... <br /> _ <br /> P-- ... City ... P <br /> Contractor's Name / <br /> --- --- License <br /> ,5.... # ee� _r Phone'.... <br /> .......................... <br /> Installation will serve: Residence.[ Apartment-House fl Commercial'OTraller Court 0 <br /> Motel E]Other ....... <br /> Number of living units:.....r./. . Number of bedrooms ..__ ..__... <br /> _ Garbage Grinder ............ lot Sire . ............ .. . <br /> Water Supply: Public System and name ..... <br /> ..:.:.-----'•-..---:-_-• <br /> ••• .......... <br /> :••••-.-•••_•••__- \U <br /> •Sand Siit • Cla _• ------••-•---- -• _•---•-- <br /> -:.•.•••••_• _• •--_-�_-. '"' <br /> Character of soil to a depth of 3 feet. (� <br /> b y ❑ Peat❑ Sandy Loam { Clay Loam 0 <br /> Hardpan Adobe 0 Fill Material ------------ If yes, <br /> type ...- <br /> ---- f <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 Ifpublic sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK v l <br /> Size:................. ............------.......... Liquid Depth .............. <br /> Capacity ---- - --- ------ Type ...-----••••...-•••• Material.--------- No. Compartments <br /> I . <br /> Distance to l nearest: Well ...... . ........... ... <br /> Foundation ........................ Prop. Line ...... .......... t <br /> LEACHING LINE [ J No. of Lines <br /> Length of each line. = ........ Total Length ------••---•-- <br /> • `D. Box ..----`..... Type Filter Material.......................Depth Filter Material ... •. .... . <br /> Distance to nearest: Well .................... <br /> � Foundation ............ Property Line <br /> SEEPAGE PIT [ ] . Depth _�..._--�. •••--------.. <br /> Diameter __.:---,-•--__-- Number _..---- •-„---- Rock Filled Yes [] Na [] <br /> Water Table Depth ..................Rock Size <br /> Distance to nearest. Well ............ Foundation .................... Prop. tine ................. <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................. .............. Date ........................ <br /> - <br /> 17 . <br /> Septic Tank (Specify Requirements) ...............:..........................:....... .... . . <br /> ---------- <br /> --- ------•.........................................---........................ <br /> Disposal Field (Specify <br /> Requireencs) - -----------........................... <br /> -p_ <br /> .. :_1�_1_ +.. <br /> ---- <br /> •---- . . <br /> Draw existing and requires! addition on reverses ej <br /> -- --••----•...---•--•••. --•--••-• . <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 Son 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman' Compensation law California.” <br /> Signed ....................... . Owner <br /> By ............................................. ----- Qjitle ............ .................... :...:.-...:....._._.. P <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY..............•. <br /> ..............••---....---••...... DATE .:... a-: --7 .._.. <br /> BUILDING PERMIT ISSUED ' DATE .• <br /> ADDITIONAL COMMENTS <br /> > 1.------------------------• -- •---.... ....................... <br /> ---------------------1......-----.......-- <br /> ..._.•.................. s .......... _..... <br /> ---------------------------------- _ <br /> '- - <br /> ------------- --------•-- ..........:_....:__---. •. --------••-•-••---... <br /> Final Inspection by: - t._... 00, <br /> •--- ... ;ase .._ `r7 " . ., .--- ----... <br /> z . <br /> x SAN JOAQUIN -LOCAL' HEALTH DISTRICT <br /> 1-'68 Rev. 5M _ •__ _ <br />