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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: ._______.:.7�{--. <br /> --_-._-------------------__.-___..__---_.__--------_--__ This Permit Expires 1 Year From Date Issued <br /> Date Issued ___7 <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made <br /> eejin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . d__ �3 Ja ---- ------------- -CENSUS TRACT -------- --------•--- <br /> ` rt -------- <br /> Owner's Name ---------- - - -- - Phone ^_��-4.'.. - - --- <br /> Address -- 4--a�--0--l. ,! %---- -- �¢�4` 7- -------- ---- - . City � `� <br /> Contractor's Name ---- � -_.License ----- Phone ------------------------------ <br /> Installation will serve: Res�nce Apartment House-[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:-.--------- Number of bedrooms _3------Garbage Grinder --------- Lot Size -------------------------------------------- <br /> Water <br /> --_-.--__-__._ .___-------------------Water Supply: Public System and name --------------- ----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam J9 Clay Loam El <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 SEPTIC TANK'] Size- � <br /> [ l � -�'-x---��-----er-`'�- ------ Liquid Depth ------�..........------ <br /> j'ZOb G'It ��aa r l 0" <br /> Capacity ____________ __-__ Type C� - Material_ .--- No. Compartments _-- _._.....- all <br /> Distance to nearest: WellSv' _______--- lad, .Foundation -----._/�_-r-....... Prop. Line --- - ----------- <br /> LEACHING LINE KA No. of Lines _______/_______________ Length of each line._ ___ _X___._ Total Length _--_ ..__± .�?.... <br /> 'D' Box ----I------- Type Filter Material ---_ __ __ p ..� <br /> . .._..De Depth Filter Material _____�g_ ______________________________ <br /> Distance to nearest: Well O r1 �M_6Adation __.__/_0__r------- Property Line .___—r..�____........ <br /> [�] p '® ❑ <br /> T Depth -----f-�---------- mer4_11X_9------ Number -------- --------------_--__ Rock Filled Yes No <br /> Water Table Depth ------------- ---------------------------Rock Size --- ' ....--..... <br /> Distance to nearest: Well °�_ _�P'f ?+�` Foundation ___!A_.____.___ Prop. Line ---, .�______..__.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------- -------------------••------------------------------------- <br /> Disposal Field (Specify Requirements) -----------------------------•--------------------------------------------------------------------------------------- --- ------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- ------------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) j <br /> 1 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: t� <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 f <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------------------------- Owner _ <br /> ------------- f-- --- --------- -------- <br /> ef�BY l- Title --- saV <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY �+ t <br /> APPLICATION ACCEPTED BY - 41-4,-:--------------------------------------------------------------•--------------. DATE ) :. --------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------...--------------------------------------DATE -------------•------------------ -------' <br /> ADDITIONAL COMMENTS ----------------------------------------------------------- ---•-------- ----------- ------------------------------- --------- --- ----------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- - <br /> -------- --- <br /> ----------------------------------- <br /> -- - - --- - = - <br /> Final Inspection by. ---- Date fT= i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev:-5M � f <br />