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CFOR OFFICE USE: S�HM r:1.0 1- <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- - Permit No. r�_3. <br /> (Complete in Triplicate} <br /> Date Issued <br /> ---------------------------------------------- <br /> --------------- This Permit Expires 1 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 County Ordinance No. 349 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---------=---------CENSUS TRACT ---------------------_---- <br /> Owner's Name -- Ar&/_?r7 ------�_v Ix.----.01 i.,f_' <br /> ----- --------------Phone,��071^.'6f."2....-- <br /> Address ----/I7-L-1---IV ---- -3 f ,. _ o_. City , <br /> .._._..---•------ <br /> Contractor's Name --------------------License # _�. � e <br /> Installation will serve: Residence [1�,partment House ❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:__3____ Number of bedrooms ------------Garbage Grinder ------------ Lot Size _________________________________________ <br /> Water Supply: Public System and name .'------------------------------------------ ---..-..----------------- .-----Private [ x <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -R ' Clay Loam [] <br /> t <br /> t Hardpan [E '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 f ] Size"_/ Liquid .Depth _._._________________ __ <br /> Capacity -..----------------- Type -------------------- Material_e4W__9AXATff No. Compartments ---4............... \ <br /> Distance to nearest: Well of h line <br /> ___/ ............Total Lengp.th h L'n ___ �,.. a <br /> LEACHING LINE [ ) No. of Lines ___________ __________ Length o g <br /> ff <br /> 'D' Box __--------- Type Filter Material ___________________Depth Filter Material --------------------- ---------------------- L''f <br /> Distance ti o nearest: Well ________________________ Foundation ____ ------------------- Property Line, ________.__._.____._____ <br /> SEEPAGE PIT Depth .__________ Diameter ________________ Number __________._-_._______--__ Rock Filled Yes ❑ No [3� [ ) p - i - �i <br /> Water Table Depth ------------------------------------- -------Rock Size ----------------------- --------- <br /> i <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..............--------- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------- ---------------------------------------------------------------- ----------:------------- --------------------------------- <br /> Disposal Field {Specify Requirements) ------------------------------------------------------------------------------------------------------------- ----------------------' <br /> ----------------------------------------------------------------------------------------------------------------------------------------- <br /> tr ---------------------------------------- --------------------------------------------------------------------------------------------- <br /> r (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 ownet or licen- <br /> sed age is signature certifies the following: <br /> "I cert y t at in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to b o e ssi ci to Wor 's pensation laws of California." <br /> Signed -. :- --- - `� .--- + = ----- - Owner <br /> BY - -------------- ------------- ----- --------- ----------------------------------------------------- Title --------------------------- --- <br /> --------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---------------------------------------------------------------------- DATE __.r-"- .-------------- <br /> BUILDING PERMIT ISSUED -'----------------------------------------------------------------------------------------------DATE ------- ---------------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> -----------------------------=-------------------------i ---------------------------------------------------------------------•--------------------------------------------------------------------- <br /> s. <br /> ----- ---- --- --------- -------------------------------------------------------------------------- <br /> --- - - --- <br /> - --------- ---- - <br /> Final Inspection by: =`-`---- ---=------------------------------------------------------------------------------- Date a -- ------------ <br /> SAN <br /> ---- - -- --SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />