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FOR OFFICE USE: �f { <br /> APPLICAWON FAR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> -------1 Q -- - --- ------------ <br /> - --- <br /> This Permit Expires 1 Year From Date Issued Date Issued .7�_ Fllo< <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 /> i <br /> I . � :7 � <br /> JOB ADDRESS/LOCATION -`- �- - .- _ CENSUS TRACT -----------------_-._---- <br /> Owner's Name --�a�-4---------'---- - - - --`�� - ----- --------------------------- - - ne 1 <br /> Address -- ------------ -- - -£- -------- -- ----- - �•=rte.' r. City �'�------------- <br /> - `��--- � t' p <br /> Contractor's Name - % - -------�j --- _-------.License # _ •. `l Phone 1­114� <br /> will serve: Residence JkApartment Nouse❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- --- Number of bedrooms __ ----Garbage Grind _,.AO--- Lot Size _K_Zl67 ________ <br /> Water Supply: Public System and name -------------A_1fh(A�__________��.-_------------------------_--------------------Private [[� <br /> Character of soil to a depth of 3 feet: Sand [:] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam;j� I <br /> Hardpan [] Adobe ❑ Fill Material -.---------- If yes, type ---------------------------- <br /> (Pl'ot plan, showing size of:lot, location of system in relation. to wells, buildings, etc, must be placed on reverse side.) { <br /> NEW INSTALLATION: (Nolseptic tank or seepage pit permitted if public sewer is available within 200 feet,) ./ <br /> PACKAGE TREATMENT [ ] ii SEPTIC TANK [ ] f�5'���°�Size------------------------------------------------ Liquid Depth -------------------------- ItN <br /> Capacity -------------------- Type -------------------- Material----------------------- No. Compartments ------- ............ ! <br /> Distance to nearest: Well ------------------------------------Foundation --------- ------------ Prop. Line ---------------------- Jr <br /> LEACHING LINE [ ] .:No. of Lines ----------/--------- Length of each line----------- Total Length �'�__a-----_------- i <br /> 'D' Box Type Filter. Material ___Depth Filter Material __.__,� `__ ._____ <br /> [ ] Lance to nearest: Well ___, __________ Foundation -----/rl).._________ Property Line --��_________________ <br /> Dist <br /> iL ' f _.__ Rock Filled Yes �` No ❑ <br /> SEEPAGE PIT Dept _._ -----___-- Diameter -- _t__------ Number ---------- -------- <br /> Water Table Depth ---------- ------------------------Rock Size ------C--- ------------------ z <br /> Distance to nearest: Well _____-�t�;-----------------------Foundation -----/�------- Prop. Line --------4 ..._...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __________________________________) <br /> Septic Tank (Specify Requirements) ---------------- -- ---------------------------------. ---------------------------- <br /> Disposal .Field (Specify Requirements) ------------ ---------•--------------------------------------------------------------------------------------------------------- F <br /> i, - <br /> -------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- - -- - --- -- -----------------;------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) 3 <br /> I hereby <br /> certify that I have;i,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 - � - k ii -- ---------f- - ---- -- ---�------------------------ Owner �.. <br /> g -------- --- <br /> Y -:--------------- � �� '+ Title �rC-t' ----------------- -- <br /> (If other than owner) <br /> II FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ \ ` > v- ---------------------------- -------------------------------------- DATE -- - ----------------- <br /> BUILDING PERMIT ISSUED ----------------V-------------------------------- ------------------------------DATE --------------------------------------- -- <br /> ADDITIONALCOMMENTS --"-------------------------------------------------------------------------------------- --------------------------- <br /> ,i <br /> ----------------------------------------------=----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- ------------------------ - -- ----------_----- ---------------- - <br /> Final Inspection by: Date _ :.Z_ -- - <br /> SAN JOAQUIN LOCAL HEALTH• DISTRICT <br /> V. <br /> E. H. 9 1-'68 Rev. 5M I� t <br />