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FOR OFFICE USE: / APPLICATION FOR SANITATION PERMIT <br /> ------ - --------------------------- ---- Permit No. --------- <br /> (Complete in Triplicate) <br /> Date Issued - -_-7 <br /> ---_--_------------------------------------------------ ' This Permit Expires 1 Year From 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATIION ------ -5- -- - CENSUS TRACT -------------------------- <br /> Owner's Name_------- <br /> �Up W-Yq-ri.�� �;�_f'✓-(Yl-�- -- -- -------------f--------------Phone <br /> Address �l --------- ` ---------------------==----------------- -•--• City _ r1- Vic' -------------------------------------- ....... <br /> Contractor's Name ------4 --'--- - ll--` ------------------------------License # I -_ Phone - - - .- T <br /> Installation will serve: Residence Eg Apartment House-E] Commercial ❑Trailer Court :❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units: Number of bedrooms ------------Garbage Grinder ------------ Lot Size ------------ ----- <br /> I L - -----Private <br /> Water Supply: Public System and name ...... - - �J- •.... ----- � /-----------1 - � •------------ E]Character of soil to a depth of 3 feet: Sand'JR 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------_---------- -- ----- Liquid Depth -------_-----------------. <br /> Capacity -------------------- Type -----/gf <br /> ------- aterial--------------------- No. Compartments ---------- .- . .. <br /> Distance to nearest: Well ------ ------- --------------Foundation -.--_--_______-_-_- Prop. Line --------- ............ <br /> LEACHING LINE [ ] No. of Lines --------------------- Leof each line----.___----- - __--______ Total Length -----------------------.-.-- <br /> D' Box ------------ Type Fitter Ma - ------------------Depth F' ter Material ---------------------------...........----- <br /> Distance to nearest: Well --------- ------ Foundation - -_ --------------- -- Property Line --------- -------------- <br /> n <br /> PIT [ ] Depth -------------------- Diameter --__-_ Number .------ ---- -------------- Rock Filled Yes ❑ NoWater Table Depth ------------------- ----------------------Rock ize --------------------------- <br /> Distance to nearest: Well ----------- --------------------•Foun ation _--------__--------_ Prop. Line --_---------------.--- <br /> REPAIRfADDITION(Prev. Sanitation Permitr# -.---_.._-_____-- ------------------ Date ---_-_--.--------_-.--------------1 <br /> SepticTank (Specify Requirements) ------------------------------------------------------------- -'----------------------------------.----------------1----------------------------- <br /> Disposal Field (Specify Requirements) --_ - 1j,----- - o - -.---- �, /i�_Q �,�jr�,� <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 become subject to orkman' ompensation,laws of California." <br /> Signed ---------------------- -/57 ------------- Owner <br /> 0 <br /> By ------ r Title <br /> ------------------------------------------------------- <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - - ---- -- - ----------------------------------------------------------------- DATE --------------- <br /> - -- -- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS -------------------- --- -------------------------------------------------- --------------- ------------------------- ----------------------------•----------- <br /> ------------------------------------------------ --------------- ------------------------------------------------------------------------------ -----------------------------------------1---------------- <br /> -------------------------------------------- <br /> -------------- --- -------------------------------------------------------- -------------------------------------------------------------------- <br /> ------------------------------------- -- -- --- - - - - - - - - ------- <br /> ------------ - - ----- -- ------------------ ---- ---- ---- - - - ---- -------------- <br /> Final Inspection by: -----L�"- r" Date ------� _--___Y'_"7__-4------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> E. H. 9 1-'68 Rev. 5M }� <br />