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jf <br /> 'FOR OFFICE USE: gpPLICATION FOR SANITATION PERMIT <br /> ---- ---- -- - --r----------.------------------------ j b`;= Permit No. <br /> {Complete in Triplicate) <br /> -------------------------------------------------------- <br /> �v t Date Issued :�7/ -� Y <br /> -__------- TKis Permit-Expires 1'-'Year From Date Issued <br /> I <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 /> JOB ADDRESS/LOCATION ------CENSUS TRACT ---------------------•---- <br /> Owner's Name -7a/./ .f/t. ', ------------------------------------------------- -------------------Phone •-----•----- - <br /> Address - ice -------s_V. /- City x � <br /> Contractor's Name License # W�,3 Phone �da�f�, <br /> Installation will serve: ResidencebrApartment House-[] Commercial ❑Trailer Court i❑ <br /> t <br /> j Motel ❑Other ------------- --------------- --------- <br /> Number of living units;--- Number of bedrooms,_�__.__Garbage Grinder -----------._ Lot Size XQ-.- <br /> aGt �---------------- ---------------------------------------•---------------Private F-1Water Supply: Public System <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] <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 pili permitted if public Psewer is available within 200 feet,} <br /> ' �. . a..e _ .� .. <br /> PACKAGE TREATMENT [ ) '.iSEPTlC TANK'[ ] Siz'e--- Liquid Depth ------------..._.... <br /> _ <br /> Capacity -------------------- Type -------------------- Material---------:------------ No, Compartments -------------......... <br /> Distance to nearest: Well ------------------ -_-____-----Foundation ---------------------- Prop. Line ---------_.......... <br /> t .A} 1 l � <br /> LEACHING LINE [ ] No. of Lines -------/____-______t_ Length of each line-------�P?___-------- Total Length ____ ___..!.......-_ <br /> D' Box (,�,v._-_ Type Filter Material`__`______.._.Depth Filter Material ----------------- <br /> y...:.... <br /> t :v . <br /> Distan'cp. to nearest: Well ------`�+._- __° Foundation _-_.-1p------___-_- Property Line ______ ________________ <br /> :_ Number ---- -- ------- Rock Filled Yes No <br /> SEEPAGE PIT_ [ ] Depth -- ------- Diameter __-4V- -' r i❑ <br /> Water Table; Depth -"---.t1a..0------------------ <br /> --------- `'`I--------------Rock Size --- <br /> Distance to nearest: Well ----� _��._--------------------Foundation --------- Prop. Line ___15r ............ <br /> I 1 4 4 <br /> Lj <br /> REPAIR/ADDITION(Prev. Sanitation Permit#1 ---------------------------- '"" _-__._-_ Date _k______---__.--_________________) <br /> t t <br /> Septic Tank (Specify Requirements)-------= ==------------------------------ ----------------------------------------------------------- <br /> Disposal Field �5pecify Requirements) ___ `� � ._ ______,&-iD---- ___ _ _________ __ ____________ -�__._- - <br /> --.-� �� s max- ---- ----- 1 ._.. <br /> - rquIred <br /> --------------' <br /> aw existing and" `"addition on reverse-side} - _ <br /> I hereby certify that I have prepared this application,and that the, ark 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 performq.nce of the work for which this permit is issued, I [[hall not employ any person in such manner <br /> as to beco object-to.Workman's Compensation laws of California." <br /> Signed -- x---- ------ Owner <br /> - `kms�".-. , N-. <br /> By ------ ------ ------------- '°: w Titl <br /> ---- ------------ ----------------------------------- <br /> ------ <br /> ------- - <br /> [ f other than owner) <br /> i <br /> FOR DV"EWISh ANLY <br /> APPLICATION ACCEPTED B <br />' . - DATE �-/-J 2" <br /> BUILDING PERMIT ISSUED --- -------- - ----------------- ----- ----------DATE - --- ------- ---------------------------- <br /> --------------- ---------- <br /> EADDITIONAL COMMENTS ----------------------------------------------------------- •------------------------ --------------------------------------- ------------------- ------ <br /> ----------------------------------------------- -------------- ----------------------------------------------------------- ----------------------------------------------- -------- ---- <br /> ------------------ -------- ---- ---------------------- -----------------------------------------------------. - <br /> --- ----------------------------------------Date -. --,2/-ri <br /> Final Inspection by, --------- ---7-- --- ----- - - -------------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />