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FOR OFFICE: USE: <br /> ....... . ..................... APPLICATION FOR SANITATION PERMIT <br /> i I Permit No. 73.' <br /> (Complete in Triplicate) "" <br /> ... <br /> '.......... ............................ ............... <br /> ThisPermit Expires 1 Year From Date lssued 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 maddein compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT'10 ��:,;7 _-... . <br /> ,........-- �P .! Fr ee_Z1.................................CENSUS TRACT ........................-. <br /> ..Prone 3 <br /> Owner's Name ......------.... ..(011.- -- -------•-... ..5�_�_1!?:..-------�.............................•--....-:..............._... ---�........7...�.. <br /> Address ........... ........... .L-6 igl _ �PdM©I`�:....-..:•--••--•-----••-•••• City ... dtae c .........--•----•----••--•--•._.._..._........... <br /> Contractor's Name ..-._.- ,.k.. $ ... t!45--------------------License .....Phone .. 6J :--. {? .7_ <br /> Installation will serve: Residence,K Apartment House 0 Commercial [)Trailer Court <br /> ,�. . -Motel.❑Other ............................................. <br /> Number of living units:- --- .--'--Numb' r of bedrooms_3,_'Garbage G nder ...------- Lot Size ......'-r ..f . _ <br /> Water Supply, Public Sys terni and name ....... ._.. .._-. %d!v Eo_a.. rivate , <br /> Character of soil to a depth of 3 feet. :Sand 0 Silt 0 Clay E'�Peat❑ Sandy Loam [] Cray Loam ❑ <br /> t :`Ha�dpoh-E] ' Adore E''Fill Maw tial ............ 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: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK f ] Size..... d -------------------- Liquid .Depth ...i6V:1..2�.f.__.._ <br /> I Capocity Type f .. Material---(Bt &,!- No. Compartments <br /> Distance to nearest: Well ..... .................Foundation .... ....... Prop.Line ....�r__..-.._._._ 13 <br /> LEACHING LINE [ ] No., of Lines ....:--og--_----__ Length of ach line..._-..�-�-�_..._.____ Total Length ....... I ........... W <br /> 'D' Box .: Type Filter Material . Depth Filter Material ..._. ..._:. • <br /> •r <br /> Distance to nearest: Well .......-� ....... Foundation --------- _-.'�-_-.- Property Line ........... ........ <br /> SEEPAGE PIT [ ) Depth ... .. .'.... Diameter ...�3.�... Number ... .................... Rock Filled Yes j� 'No <br /> • Water Tcib[e Depth Y._Q Rock Size _r �.:." ................. <br /> � <br /> ---------- ------,-•---•-•- <br /> Distance to nearest:Well ------=: C?_A.." ...............Foundation ....�Q.._..... Prop. Line _.___--._°`--..._.:. 7 , <br /> i .. <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# :___....._-___-•-••_________________________ Date .................................. <br /> k <br /> Septic Tank (Specify Requirements)......... ......- -----------=---------_---------------- ------- ............................... ------....... _ <br /> fDisposal Field (Specify Requirements) ....................................................................... aw.............................................. <br /> --------------------------------------•------------------....------------....-------•-------•-•--y-- <br /> ------------------------------------------------------------------------------------------------------------ ................................. -------------------------------------------------- <br /> (Draw <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 Joaquln <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 /> k � <br /> Signed ........ ----- =" == ............ Owner 117- ...w <br /> By .................4%. Title ' .. - .. '!1............._.......................... <br /> (if other than owner) " <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY......... ..... . .. ...... :.......-..............:...... DATE ....- .-1` -?_3 <br /> BUILDING PERMIT ISSUED ---•---==----- -._:_ _. L DATE .... ............•-----•-..._.. ........ <br /> I ADDITIONAL COMMENTS _______________________ . :.. ..'p <br /> ------------------------------------ <br /> --------------------••...-•---•••........... .................................................... •...-_ ...... ................................................. <br /> .....-.. <br /> ...-------------•---------------•- f <br /> ..... .. ... . ............ <br /> .. <br /> Final Inspection by: ..... ...... . .. .... -_._._.................... . Date .. .... _ <br /> !--•--• ...... <br /> l SAN JOAGUIN LOCAL' HEALTH DISTRICT <br />