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FOR OFFICE USE: APPLICATION SANITATION PERMIT <br /> - --------------- ------�- ------------ - Permit No: <br /> (Complete in Triplicate) <br /> This Permit Expires ] Year From Date Issued <br /> Date Issued '--21-7 72" <br /> _ <br /> ------------------------------- --------- -------------- <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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ' t -T- �-o <br /> JOB ADDRESS/LOCATION -fes �. - - CENSUS TRACT <br /> Owner's Name _ �. �� -� ~-----------------------------------------------------Phone <br /> Address AlIV l&W--_-�. e e4ZOLSWS,-T)-------------------------- City 1 r P9�/�fs <br /> Contractor's Name ���� ear� G =------------------.License Phone -------------------•---------- ' <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑ Other _R47---------------------- <br /> Number of living units:------------ Number of bedrooms ______""-__-Garbage Grinder ------------ Lot Size <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------- ----------------PrivateX <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam El -� <br /> 411 <br /> Hardpan ❑ Adobe ❑ Fill Materia! ------------ 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-----------------------------------.------------ Liquid Depth -----------------.-------- <br /> Xf��ir/�J Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distan� cnearest., Well ------------------------------------Foundation ---------------------- Prop. Line -------------- <br /> LEACHING <br /> ---------LEACHING LINE 9€-1-itft __.�.,fJ�f 3f?--`--- Length of each line------_____________ __ f <br /> _ _____ Total Length �4_�_,.�Ca._.._.-- <br /> vt��'j` 'D' Box �.�+s1'-- Type Filter Material��_x ------Depth Filter Material --- --------------------------------- <br /> 0G`r � Distance to nearest: Well __/0-0_r_____-_- Foundation ./0-_______________ Property Line _-,e5-_-_--_._.__. <br /> SEEPAGE PIT [ ] Depth -"---- ------------- Diameter ________________ Number ------------------------ _ - Rock Filled Yes ❑ No ,c] <br /> Water Table Depth ------------------------------------------------Rock Size ---------------- ------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.---____________----------1 <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------�--------�--f---------------------- ------------- -------------- <br /> Di sp sal Field (Specify Require a ts) �_ _- ---- 7--"---i---- --- - ---- --•--------------- <br /> . .�� - ----- �-----�• ' �Xr .i -----------"-••--------- <br /> -- ---------- ------- ----------- --------------------------------------------------------------------------------------------------------------------------------- <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 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, 1 shall not employ any person. in such manner <br /> as to becom bject to Workman's Compensation laws of California." <br /> Signed Owner <br /> ------ Title --------------------------- ----- ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . " c.� ----------------------------------- DATE .----R 7 = -^-7-Z---- <br /> ----- - --- - <br /> BUILDING PERMIT ISSUED - --------------------------------------------------------- --------- <br /> ------------------------------DATE -------------•------------------------•---- <br /> ADDITIONALCOMMENTS ------------- ---- ---------------------------------------------------- ---------------------------------------- -------- --------------------------- <br /> -------------------------------------------- ------------ -­IN-------------------------------------- ------------------------------------------------------------------------ <br /> --------------------------- <br /> - ------------------------- ----- -- -- -- ---- ------------------------- - -- ---------- ---------- - ------------------------------------------------- <br /> Final <br /> -------- -- -- - ------- --------Final Inspection b ----------------------------------------------------------- ----------------------Date ------0y__-"Z_,r- 3 --------------- <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />