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' .I <br /> �a <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: � �.- - <br /> -----------f.--------------------------------------------- (Complete in Triplicate) <br /> -`------- - ---------------------------------------I� - - Y <br /> . Date issued <br /> This Permit Expires 1 Year From bate Issue , <br /> - --------- <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. ion <br /> J549 and existing Rules and Regu ats: <br /> , <br /> ---- <br /> 1-�-- CENSUS TRACT _-SAR------- <br /> -� ----- -- ------JOB ADDRESS/LOCATION; <br /> - <br /> --- - - --- ------ <br /> /� f! n <br /> Owner's Name ...p'-fi /;;,e........ ------- e <br /> ----- RPh <br /> t{ City afif ' ----•-•------ <br /> r <br /> s. <br /> ------� <br /> ' J -- <br /> Address ' Phone ------------------- ---------- <br /> Contracto -------------------------------------------------- <br /> Installation <br /> f 3 <br /> -�'s Name ------ -} - ------ ----------- ----------- ---License # ------- :---------- - - <br /> Installation will serve: Residence•AApartment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑Other ---- ------------------------------ -------- <br /> Garbage of bedrooms Grinder <br /> filo--- Lot Size -----J_ a � �7-` •- <br /> er of <br /> Water Supply.IPubIiclSystem and name _---�s�` s --'--`------.U `�'�` ----- -----------------------Private K <br /> - ---------------------------- <br /> :of soil to a depth 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam�j <br /> Character Hardpan F1 Adobe F1 Fill MaterialNQ'--- If yes,type ---------------------------- <br /> 4� <br /> If: 0 <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed .on reverse si e. 4 <br /> NEW INSTALLATION: No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> TREATMENT r Size- __ --(n-- ------ Liquid Depth -------------------------- <br /> PACCAG !�j SEPTICTANK�[ <br /> --^- •---------- <br /> Capacity ��_��-�-- - Type -------------------- Material '��v---- No. Compartments � 0 <br /> Foundation ---- Prop. Line -------------------- <br /> Distance to nearest: Well -_�Q� -/-?/------------- d FT <br /> i <br /> G LINE [ ] No. of Lines ____' -__-__-_ -- Length of each line........ <br /> �'------------ Total Length __ - -------•------- <br /> tEACHIN _ -Deth Filter Material -------------------- <br /> D' Box ------ --- Type Filter Material ------------------- P •--------------- ------- <br /> 11 _ <br /> . istance to nearest: Well -------------f------r-- Foundations- Property Line --------- -------------- <br /> Distance <br /> E <br /> Depth Diameter _ g ---- Number ........ Rock Filled YesX No <br /> �_ PIT [ ] ePth �4-------------- - - <br /> Rock Size ----- ---- <br /> `' <br /> Water Table Depth _- -----------------------------is <br /> --------- - <br /> tDistance to nearest: Well ------------------------------i----- ==Foundation _--~=------------ Prop. Line ---------------------- <br /> . --- Date ---------- ------------ ------I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------- Pff.. <br /> IIr ------------------------ <br /> Septici!Tank (Specify Requirements) ------------------ ----------- ----- ----------•----- <br /> ------------------------------ <br /> ------- - : <br /> Diso, ------------------------------- <br /> p sal Field (Specify Requirements) ------------- ---'---------------------------------- <br /> '' <br /> ------------------------------ <br /> ------------- <br /> ------------------- ----------------------------------------------- <br /> e, <br /> hereb --------------- <br /> ;, (Draw existing and required addition on reverse side) <br /> yi 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,* <br /> Joaquin Local Health District. Horne 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 sub* t to Work n's Comp sation laws of California." <br /> C it I <br /> Signed Owner <br /> - rY <br /> Title ----------------------------- ------------------- <br /> ----------------------- <br /> r (lf other than owner) f _ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __--- --__-- DATE -- -- - <br /> ----------- -------------------------------------------------- <br /> BUILDING PERMIT ISSUED -._ ---------DATE-=- = -- <br /> ------------ <br /> ADDIT! ---------------------------------------------- ---- ----------- <br /> ONAL COMMENTS - <br /> ---------------------- <br /> _- " ---------------------- ----- <br /> ----------------------------------------:-------- - -------------------------------------------------------------------------------------------- ----- <br /> ------------ <br /> ----------------------- ---- - --- - --------------------------------------------------------------------------------------------=------------------ <br /> Final In ection b ---- --------------=-------------------------- <br /> Date � ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> E. H. 9 1-'68 Rev. 5M <br />