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FOP OFFICE USE: <br /> t, . `- APPLICATION FOR SANITATION PERMIT <br /> ---------- - 1� S- <br /> (Complete in Triplicate) Permit No <br /> ----------<------ --------------------------------------- <br /> ---------- -------------------------------------------- <br /> --------------------------------------..-._---.-__________________________________________ __ This Permit Expires 1 Year From bate Issued <br /> 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 Ordinan a No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC .--------- f -------- % _C �' -------- ----------------CENSUS TRACT -------------- ----------- <br /> n <br /> Owner's Name _ ___ ------ ff 1. 111.Srr _ <br /> �Fi�- - --------------- ------ Phone <br /> Address _________________f� (/`��f - <br /> Contractor's Name -------- ---- ---- : Licene_#� Pf---- _ / <br /> Installation will serve: Residence partment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- / <br /> Number of living units:________ Number of bedrooms __2 __GarboAe Gri e� _.__ Lot Size __W" _X__1 _.__.___.. <br /> Water Supply: Public System and name - ------ -- - --�- <br /> -A --------------------------------------f "--------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay E] Peat El ` -Sandy Loam -E] Clay Loam ❑ <br /> Hardpan ❑ Ado6 aterial ------------`•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 pubfic'sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-[J r, r <br /> Size --=--------------=�--- ---------------- Liquid Depth ------_---------_--_,_. r1 <br /> Capacity -------------------- Type ---------------;.`-"Material---------------------- No. Compartments <br /> Distance to nearest: Well ----------------t-------------------Foundation ---------------------- Prop. Line ---------------------- <br /> I <br /> LEACHING LINE [ ] No. of Lines ------------------------ Lengih of each line---------------------------- Total Length -----------,---------------- <br /> 'D' Box ____________ Type Filter Material)---------------------Depth Filter Material _________________ ._ __.____-_ <br /> -- ------------- <br /> Distance to nearest: Well ----------------------- Foundation ------------------ Property Line _______________________ , <br /> SEEPAGE PIT [ ] Depth _ __________________ Diameter --------- <br /> --- Number _.-------------------------- Rock Filled Yes ❑ No 10 , <br /> Water Table Depth -----------------------i---------- ------------Rock Size -------------------------------- <br /> I <br /> Distance to nearest: Well ------------------------------- -------Foundation --------------- ---- Prop. Line ........._............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..------_-------------------------6______ , Date ----------------- __________.___) _ R <br /> Septic Tank (Specify Requirements) ___________________------------------ <br /> ____ __ ----- <br /> Disposal ield (Spec' Requirements) /�'Z� .�1 - ?f7------ `�C/-------- <br /> -------------------------------------------------------------------------- <br /> -------------------------------- <br /> --------- ------------------------- --- ---- - 'T <br /> r , <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: I _ , ._ _ I <br /> "1 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 /> BY Title �1.- <br /> {If oth t n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --j-7'a-4-- - -------------- ----------------------------------- DATE _5'-., ------------7-/------ { <br /> BUILDINGPERMIT ISSUED ------------- -------------------- ------------------------------------- --------------:--------------DATE ------------------------------------ ------ <br /> ADDITIONAL COMMENTS -------------- <br /> ------------------------------------------------ <br /> ------------ - <br /> r <br /> ---------------------------------------------- ! <br /> ------------------------------ -------- - -- --------- - - ----------------------- --1------------------------------------ ------------------------------------------- - ------- <br /> ---------------------- ------------------- ----- _____________ - F_____________________-___._____.____.'____.____________________._--_______.__.__ ___ ._ _ ___ E <br /> Final Inspection by: -------- --- ---- --- ---- -----------------------=------------------------------------------Date s 7l <br /> O QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M { - ` <br />