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` FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------- i <br /> (Complete in Triplicate) Permit No: <br /> This Permit Expires 1 Year From Date Issued Date Issued <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO ION .!_770 ---------------------- ------- -------_--_CENSUS TRACT __9_9_4--------------- <br /> Owner's <br /> _S9-4-------------- <br /> Owner's Name _ ------ ----- ------------------------------------------ -------------------Phone ------------------------------------ <br /> Address -------------- ---- --------- ---- ---- - -- --------- ---- --------- -------- city <br /> ----------------------------------- <br /> AddressCity -- ---------------------------------------- <br /> f-— <br /> e ------ hone <br /> ----- <br /> Contractor's Name --- - - ----- -- —-- - - ------ ------ -- -L-------- -- -----.License # � - . P <br /> Installation will serve: ^ ----Reside a Apartment House❑ Commercial-❑Trailer Court ',❑ <br /> Motel ❑ Other ---�---`------- ------------------------------ <br /> Number of living units:---I------- Numbnof bedrooms 'T____---Garbage Grinder ------------ Lot Size -------------------------------------------- 1 <br /> Water Supply: Public System and name ------------------------------------------------)_-------------------------------- -----------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ - Clay [] -Peat❑ Sandy Loam -C] ­Clay-Loam <br /> Hardpan ❑ Adobe❑ Fill Material ----- ------ If yes, type ---------___________________ <br /> (Plot plan, showing size of lot, location of system infrelation to wells, buildings, etc. must be placed on reverse's'-de.) <br /> NEW INSTALLATION: (Nb septic tank or seepage pit permitted,if..public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ,r x.SEPTIC TANK[ ] Size__�___ T_'_*_ .____.______---_I-_----;�-- Liquid Depth ------="___-_-___�___,_.... v <br /> Capacity ---------------- Type -------------------- Material-,-------------------- No. Compartments ------------­----- <br /> -----•- v . <br /> Distance to nearest: Well ____________________________________Foun `i F at' %Ka p d <br /> ion --- Pro Line <br /> LEACHING LINE [ ] No. of Lines Length of each line________--- ------------ Total Length - = <br /> --------•------------- � <br /> ------------------------ Len � <br /> r - <br /> 'D' Box ------------ Type Filter Material --------f----------Depth Filter Material ------------------------------------------•- <br /> Distance to nearest: Well _______________________c Foundation ------------------------ Property Line ---________________--___ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter 11---------/--- Number ___ __..________- Rock Filled Yes ❑ No 0 <br /> Water Table Depth --------------------------/----------------------Rock Size ------------------------------ <br /> Ir <br /> Distance to nearest: Well ____________ ________________________Foundation --------------------- Prop. Line __________--- -------- <br /> 9'b qI_�s b� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .__G�----------------t------------------ Date ___ _ __ __ _________---_------) <br /> Septic Tank (Specify Requirements) _________________ ,�- <br /> Disposal Field (Specify Requirements) --- _----- 5 '---- ----- ------------------ <br /> `, I <br /> --------1+1-Jr---- ---------- <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: <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 Workman's Compensation laws of California." <br /> Signed ------------------------------ Owner <br /> :--- -- t.le� .d. `--------------------- <br /> (If other than owner) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ -, -- ------------------------------------------- -----------. DATE _.�-'� .-L . 7--------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------- --.--------------- --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------- ---- -------------------------------------- --------------------------- <br /> --------- ------------------- -------------------------------------------- --------------------------------------- - ----- <br /> -------------------------------- ----- --------- -------- ------------- -- ------------ - //-- <br /> --- - ------- <br /> Final Inspection bY: -------------------------------------- ------Date - ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_ H_ 9 1-'68 Rev_ 5M <br />