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I <br /> FOR OFFICE USE: <br /> ----- ------------------------------------------ <br /> �- APPLICATION–FOR SANITATION PERMIT Permit No: <br /> --- ------ <br /> ---------I---------------------- --------------------I (Complete in Triplicate) <br /> `` <br /> ---------------__.____-_-I-_ - This Permit Expires 1 Year From Date Issued Rate Issued l�= :7y-- <br /> 0 07---a q.O—1-5, <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 /> IM Lots ISS,_ ..•" <br /> - _ �cC_ck .b ` (' 1'S`�P�ENSUS TRACT A.Y7---------- <br /> LO f <br /> -: <br /> JOB ADDRESS/ ION . <br /> Owner's Name ------------------------------------------------- --------------------Phone <br /> ---------------------------•-------- <br /> Address ---------- M _9?-- <br /> � J city <br /> Contractor's Name ---. --- ------ -----------I--------------------------------------License # 3 — Phone --------_-•------------_ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer Court l❑ <br /> Motel ❑Other _. -------Ab - <br /> Number of living units:---.-------- Number of bedrooms _----YGarbage Grinder -.----------- Lot Size -._.-__---_- -------- ------- -.---- <br /> Water Supply: Public System'Iand name --------------------- ---•---•---------------------------------------------------------------------_----------Private [ ]' <br /> i <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay [-❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [ Adobe M 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 aseptic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth <br /> Capacity -------------------- Type ------------- Compartments-- --- Material----------- - .-------- No. Com ................. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------:-------- <br /> LEACHING LINE [ J No. Ilof Lines ------------------------ Length 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 ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> I <br /> Distalnce to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REP IR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_} <br /> 11 <br /> ptic Tank (Specify Requirements) - -------------------------------------------------------- <br /> ------------------------- ---------•------- ----- ------------ <br /> IM <br /> Disposal Field (Specify Re uirements)_ --_Cr -_-.__. ....'-__--- . -.---__ - ----- <br /> r --------------------- <br /> i`------ ------C--- 1 ------- ------ �� ,r ✓ ----- <br /> -Zk <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 performiiince of the work for which this permit is issued, II shall not employ any person in such manner <br /> as to become subject to Worllman's Compensation laws of California." <br /> Signed - I" Owner <br /> BY �� - r --- - I.- ------ - ---•------------- - ---- Title __ _ _' <br /> (lf other than owner] <br /> If FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By.--- - ------------ ------------- --------------------------- <br /> ----------- ----------------------- DATE .. - . <br /> BUILDING PERMIT ISSUED <br /> _:------------------------------------------------------------ ------------ ------------;--------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ---- <br /> ------------- �M <br /> .i. <br /> ------------ ------------------------------------------------------------------------------------------------------I------------------------------------------ -------------------------•- <br /> ll. <br /> --------------- -------------------------------------------------------------------------- ------- <br /> ---------------------------------------- -- <br /> FinalInspection by: ------ - --------- ----------------- ----------------------------------------------- ----------------------------Date <br /> ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />