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FOR oFFlce USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..-._--___:--- - <br /> (Complete in Triplicate) <br /> 4- r Date issued <br /> ��/l%G17. 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 ith C Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ---- ------- ---- ,- -- ---- -------- ---CENSUS TRACT -------------------------- <br /> Owner's Name fl — '� C f � Phan�V� <br /> Address - -------- --------• .. Cit v G 5{J --------- ------------------•-•------ <br /> j � _ , <br /> Contractor's Name ----License #`���i� �.� Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trader Court-;QYwr.~ <br /> Motel ❑Otherl_ •i <br /> -------------------I----------------------- <br /> � f <br /> Number of living units:.___]----- Number of bedrooms -_'�--_GarbageI Grinder -___-.--___ Lot Size -- -__1S--- F_ <br /> Water Supply: Public System and name -------------------- ------ I ------------------------------------------------- -Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'F] Silt❑ �3Clay ❑ Peat E] Sandy loam [I Clay Loam:❑ <br /> Hardpan ❑ AdobeFiIIIMayerial -----*"' if yes,type ------------ -_.- -__-__- <br /> i ' 1.N <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plaed on reverse side.) <br /> 4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feat,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size----'----- ------------•------------------------ Liquid Depth -------------------------- <br /> 1 <br /> Type _ Material--------------` Moo. Compartments -------------------- <br /> Capacity <br /> --------------- vp r F <br /> Distance to nearest: Well - --------------------- ----------Foundation -__---rT�--------- Prop. Line ---------------------- <br /> t ttrLEACHING LINE { ] No. of Lines ------------------------ Length of each line— atal -Length I--__-.---.----.----------- <br /> 'D' Box __.--___.__ Type Filter Material ----------i--_Depth FilteryMaterial ---------------------------------------- <br /> I <br /> ---___ - - <br /> --------•----- ' <br /> I A s {{ <br /> - ---- ----- -- -- <br /> Distance to nearest: Well ---- ------------------- Foundation---------1- ---------! Property Line -------------..--------- <br /> Ir <br /> -------- <br /> I �t " L--;-- - Rock Filled Yes No {] <br /> SEEPAGE PIT [ j Depth ------------------- --------------L, <br /> - 1------ -- ----- ry .. ❑ <br /> _ Diameter ------------- <br /> u •1_R�ck.Size -------------------------------- <br /> Distance <br /> ----- -=-------------------- <br /> Water Table Depth ------------- -- <br /> ii " 1 Prop. Line <br /> Distance to nearest: Well .----_i_--_-,:=--- '------------ -Foundation <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------I------�-`---- --------- - �:Dates_ _--_----- .. ----:-----------] <br /> Septic Tank (Specify Requirements) --------- -- : ------ ------------------ ---------- <br /> ---lc­:� & <br /> posal Field pecify Requir meets4 - - <br /> 4 _ ( , - -P- --- <br /> iii k <br /> -------------- <br /> IJ ------------------------------------- <br /> (Draw existing and_required_add.ition 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 Ordinance's, State Laws, and Rules and Regulations of the San.Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: �C <br /> "I certify that ' the performance of the work for w ' h this permit is:issued, I shall not employ any person in such manner <br /> as to be a to y9maW.s C pe cation ws of California." 9 0% <br /> Sig d -- -------------- Owner <br /> B <br /> ------------------- ----------------- <br /> ---- Title _- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED --------/�[ ----------------------- DATE _------��---- = <br /> ------- -- - - - - <br /> BUILDING PERMIT ISSUED -- -------DATE ------------------------------------------- <br /> - ------------------------- <br /> ------------- <br /> ADDITIONAL COMMENTS - ------- <br /> - --- -------------- <br /> ----1 Qr ` ------- � t►t------sly. -LL fir-------- v-b � - - ��rs------C9�rLtL �Q<Qa <br /> t ---------------------- _:___----- ------------------ <br /> i <br /> - --------- <br /> ----------------------- <br /> ----------------------------------- - <br /> Final inspection by: _- Date _--- " ----`---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />