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FOR OFFICE USE: <br /> .APPLICATION FOR SANITATION PE._16 <br /> h Permit No. <br /> (Complete in Triplicate) <br /> ---------=------------------------------------------ - <br /> ��---- This Permit Expires 1 Year From Date Issued Date Issued <br /> i <br /> Application is hereby mad to the San Joaquin Local Health District for a permit to construct and instal" the work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION Y,I' <br /> " I - -- 4A F/7 /Z 71 F <br /> ENSUS T <br /> RACT -----------------_ ------- <br /> --------------- <br /> Phone <br /> ______ <br /> PhoneOwner's Name -1 --------------------------------------------------- <br /> ------ -- ------------------ ---------------------- <br /> Address ------ -+-------------------------------------------------------------------------------- city ----------------------- - -----------------•--•---•---•-- <br /> Contractor's ------------------------------ <br /> Installation <br /> .� <br /> Name -.- _ .._I <br /> .��__�-r-�_--- �--r�..c=-- -----------.License # t�.�_��"�--- Phone ---- ------------------------- <br /> Installation will serve: Residence [!rApartment House-[] Commercial ❑Trailer Court ;❑ <br /> t Motel ❑Other ---------------------------------- -------- <br /> Number of living units:---- -- --- Number of bedrooms - ___Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water Supply: Public System! and name ------------------------------------------------------------------------------------------------------------.Private <br /> I <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [Z Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I'll SEPTIC TANK.[ ] Size------------------------------------------------ Liquid Depth _____.__-__.._________-___ <br /> Capacity ------------------- Type -- -------------- Material--------- ------------ No. Compartments ---------------------- <br /> Distance to nearest: Well ------------ A----------------------Foundation ----------------------- Prop. Line ---.------------..-..- <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of: each line----------.----------------- Total Length ,_____-____-____-_........__ -\ <br /> E <br /> 'D'M Box ------------ Type Filter Material ---'-----------------Depth Filter Material --------------------.-----------.....------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. ---__________-__--. -- <br /> SEEPAGE PIT [ ] Dell <br /> -------------------- Diameter -------------.__ Number --------------- ------------ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------=--------- <br /> Distance to nearest: Well ----------------------- --------------Foundation =------------------- Prop. Line --------------------_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#---_____--_-------------------------------- Date ----------------------------------I <br /> Septic Tank (Specify Requirements) ----------- 1,�a - -------------------------------------------------------- ---------- ---------------------- --- <br /> € ---- <br /> ------------------------------------- ._ <br /> Disposal Field (Specify Requirements) .4 `C" = <br /> ---------------------------1 y-�-- r- � = -------------------------------------------------------=-- ----------- ------------------------ <br /> ---------------------------------------- - -------------------------------------------------------------- <br /> k - <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 dome in accordance with San Joaciuln <br /> 3. t <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 Com ensati.on laws of California." <br /> Signed - - --._ ._ __, <br /> --------� Owner ... <br /> I` BY ?f ' `"` ° Title o----------------------------------- -------------- <br /> (If other than"owner) <br /> EOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._ - --- - --------------------------------------------------- - ---- -----------•------ <br /> BUILDINGPERMIT ISSUED�---------------------------------------------------------- --------------------------------=--- ----------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS! - -------=---------------•----------- <br /> i <br /> ----------------- ----------------- -------i------- -------------------------------------------------------------------- --------------------------------w­-------------------------- --- ------------ <br /> ------------------ - --------------------------------------------------------------------------------- - -------- <br /> ----- - - - ---- <br /> Final Inspection by: ---- ------ ---- -- -------- Date = " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t .. <br /> E. H. 9 1-'68 Rev. 5M <br />