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FOR OFFICE USE: <br /> APPLICATION 7 FOR SANITATION PERMIT <br /> '.f Permit No. ___7/7_-7 <br /> [Complete in Trl" hicitel <br /> - ------�- -------- -------------- ---------------• Date Issued <br /> This Permit Expires 7 Year From 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 made in compliance with ounty Ordinance No. 5 and existing inRul s and Regulations: <br /> JOB ADDRESS/LOCATION .----- -�' - �.--- --��,J----------------- 1 --`2(NS CENSUS TRACT <br /> Owner's Name -- 'l _- -- <br /> n:�� `3 ------------------- _ . Phone "- - _n_�9 <br /> Address -------- 'e- Cit 57C > �\. <br /> PrJ`-'� Y <br /> Contractor's Name Q -------------------------------------------------License # Phone <br /> Installation will serve: Residence M-�artment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms _77_3------ Grinder -r-�O--- Lot Size ----L_.___- -�_�'�--�j------ - <br /> Water Supply: Public System and name --------------------- w -----------------------------------------------•-----:-----Private [_� <br /> Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> 11 <br /> Hardpan ❑ Adobe 11 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 /> I NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- �+ <br /> Capacity -------------------- Type ------------------- Material---------------------- No. Compartments -------------- <br /> Distance to nearest: Well --- --- ---------------------------Foundation ---------------------- Prop. Line ------- --. ---------- �! <br /> LEACHING LINE [yam No. of Lines _-_i___1 -- L th of ach line----___-- --V-- ----- Tatal Length __ ____�S?� -----•-•-- w <br /> 'D' Box ----VTyp Fi er aterial c- - ------Depth Filter Material -------��-------------/------ <br /> �'istance to nearest: II - -- -----------_--- - F undation -___--/¢--------- Property Line --- ---. __....__ <br /> —� ----. Rock Filled Yes No <br /> SEEPAGE PIT [��l Depth __- - ___-- _-- Dia eter -- _ _ 3_-- umber ----------- ---- --- <br /> I Table De {h - _____- Rock Size ___. - -- ---------- <br /> Water P { <br /> Distance to neo t�iNell ---------------- -- - -- --------Foundation --------------------- Prop. Line ---------__------- <br /> ----------------------- <br /> REPAIR/ADDITION <br /> ---------•-•-•------- <br /> REPAIR ADDITION{ ev. Sa itation P r 't# --------.--------------- Date ------------------- -------------- <br /> --------------------- <br /> 1 <br /> Sept c Tank (Sp ify Requjirements------------ 1------------ ----------------- � - ,.. <br /> i Disposal Field pecify Require�ents) ----- `.c /�Jr---------- rf' � lGr <br /> ------------------------------------ <br /> --------- --------------- ----�have ------ ----------------_.--------------------------_-__-------------------- -_------__------ ------__-----.---------------- <br /> r ( raw existing and required addition on reverse side) <br /> I hereby certify that I d 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 /> r as to becom s bject to Workman's Compensatio laws of California." <br /> y Signed- - <br /> - - Owner <br /> f -------------- <br /> -------------- ------------ Title a -----...------ --- <br /> --------------------------------- <br /> (If other than owner) <br /> FO RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- ----- - -- --- -- - ---- - - ------------------------------------------------- • DATE r - ------------- <br /> BUILDING PERMIT ISSUED ------------ ----- - -- ----- <br /> -------DATE ----- -- --------------------------------- <br /> ADDITIONAL COMMENTS --..------- ---------------------------- <br /> r -------------------------- <br /> -- --- <br /> ------ <br /> -- ------- ----- --- ---- <br /> FinalInspection by: _----- ------------------ -------------- -------------- --------- ----- ----------------------- Date ....---------------------------------------- <br /> SAN <br /> ------------ --------------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_ H. 9 1-'68 Rev. 5M <br />