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r � <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- ---- ---------------------------- v <br /> z <br /> _ �. _.. --.. Permit No. --��- ------------ <br /> + (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued 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 a plication is mad n compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J�,j�O S fit, Lr C C� <br /> JOB ADDR SS/LOCATION . -- _-- _ - - ------- ----- -------/ ------------L y0D---5--- j.__CENSUS TRACT -Jr-�- {-..----- <br /> Owner's Name ._ - <br /> ..--- - -� �' - ------ ----- --«--------- ----- Phone - --- ----- --- <br /> Address - j 5 ---- ---cc-------- ---------- -------------------------------- city / G <br /> Contractor's Name _. 4 ' --�3 `p--------------------------------License #.Z— _ l_ phone .! _ o��_ 1./.. <br /> Installation will serve: Residence WApartment House❑ Commercial ❑Trailer Court s <br /> Motel ❑Other -- ------ ------ ------ <br /> Number of living units:--.-/r...... Number of bedrooms _,.3-_ Garbage Grinder Lot Size ____G _C ,e e_______________ <br /> Water Supply. Public System-and name ------------------------------------ -----------------------------------------__-------------Private ' <br /> Character of soil to a depth-of,3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam.❑ <br /> Hardpan ❑ Adobe 9 Fill Material _?V,?--- If yes, type ____________________________ <br /> (Plot plan, showing size of lot, location of system n relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) a <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size____-f"_ -�.anX-_y' -_.______ Liquid Depth ____Y -------------- <br /> Cpacity lad a--- -- Type ���__ Material___ No. Compartments ____ —___._....-- <br /> istance to nearest: Well --------'F_©--------------------Foundation _____/__'>___________ Prop. Line ----.:�7__.__.______ <br /> LEACHING LINE [ No. of Lines i__._x ______________ Length of each line------7_`5.:____--------- g <br /> 'D' Box - Type Filter Material ---0�---------Depth Filter Material - -------- ____________________________ <br /> Distance to nearest: Well -------J�"'_-0------------ Foundation ---/__6 Property Line ______ ___ <br /> SEEPAGE PIT Depth --- .V ------ Diameter ------7�------ Number -------------- ------ Rock Fig ed Yes $T No 0 <br /> Water Table Depth -------------------0--`�-------------------Rock Size ---- <br /> Distance <br /> --Distance to nearest: Well --------- <br /> /- __ <br /> If______________________Foundation ___1 _________ Prop. Line ___s .._. ._------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_____________________________________ Date -------------­ <br /> -- <br /> Septic Tank (Specify Requirements) -------------------- -------------------••------------------------ I----------------------------- <br /> Disposal Field (Specify Requirements) ------------ - ----------------- -----------------------------------------------•--------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> .-.. <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 performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to )Secome subject to Workman's Compensation laws of California." <br /> Signed ------------------------ ---------------- -------------- Owner <br /> BY Lfe' f -- - <br /> ----------------------------------- --- ------------- Title ------------------ <br /> (If other than wner) <br /> # FOR DEPARTMENT USE ONLY <br /> APPLICAwTION ACCEPTED BY --___�_�_j3--'D-------------------------------------------------------------------------------- DATE -----5-�'-- -------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ---- --------•----------------------------- <br /> ADDITIONAL COMMENTS -- ------------------------- - - ---------- ------------------------------------------------- --------------------------- <br /> ----- ----------------------- --------- ----------------- ---- ------- -- --- -- ------------------------------------------------------------------------------------- ------ ----- <br /> --------------------- -- ------------- --- --- - - -- ------ ---- ----- -- - ---------------------------------------------------- ------- <br /> Final Inspection <br /> ----- ---- - --- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />