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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit o_ <br /> ------------------------------------ <br /> -------------------- This Permit Expires 1 Year From Date Issued Date Issued _:_. __r✓��_7Q <br /> 0(-9 - bsO-17 <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,.CounOrdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATJ1DN -YgWzu _1-r -fc- ---CENSUS TRACT ---------------- <br /> Owner's Name(,,, -- - Phone_ ,� <br /> Address � f ------�----f--�--�-_------------ City C/lL --------------•-------------- ------------------------ <br /> Contractor's Name ________ fd_ _______ __ E_ L'.G6_ - ___________.License #/ cYa'_______ Phonel �a_ <br /> -------- <br /> Installation will serve: Reside ce [] Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ----- --- ^--- --------------- <br /> Number of living units:.__ -_ Number of bedrooms -----------Garbage Grinder - `_____ Lot Size _____Q___________ ___—_________ <br /> Water Supply. Public System and name ---------------------------------••---------------------------------•------------------------------------------Private [r <br /> Character of sail to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •01"' 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 [ ] SEyTIC TANK'[ Size_�__.�'___s __..�`_-`_ _ <br /> __ _________________ Liquid `[?aptf� Al____---------- <br /> ______ <br /> Capacity � _c}_-Vs---- Type-------- Material__COACT---------- No. Compartments A----------------- <br /> Distance 1 neart: Well ----------60_ ------------------Foundation ______/_____________ Prop. Line ___. ___-_____------ <br /> LEACHING LINE No. of Lines ---------/------------- Length of each line--------/ip.I----------- Total Length -_____-_____-_ <br /> 'D' Box ._...,..----- Type Filter Material ----`-e2_'---Depth Filter Material _____!!F--N_______________________________ <br /> Distance to nearest: Well --------S,0 f________ Foundation ---------/b._/------- Property Line ----S............... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter -------.-------. Number ------------ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------.------ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------- ----------------------------------------------------------------------------- -----------------•..•_-------------------------- <br /> Disposal Field (Specify Requirements) -------------------•----------------------------------------------------------------- <br /> -------------------------------- <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, I shall not employ any person in such manner <br /> as to become subject to aman's Compensation laws of California." <br /> Signed --------------------------- ---- ------ - ---- OwnbxL�471&1_ <br /> BY --------------- Title ------------------- <br /> (I e - I <br /> ----- ---- --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ –_C- -- --------------"-- -------------------------------- -=--------------------. DATE ------ 7---'�----------------------- <br /> BUILDING PERMIT ISSUED ------------------------------ -------------------------------------DATE ------------ ----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- --------------------------------------------------------- <br /> - - -------------------------------------------------------------------------------------------------------- <br /> --------•-------------- <br /> -------- <br /> ------------ --------------------------------------------------- --------------------------------------------------------- ---------------------------------------------------------------- <br /> ---------------------------------------------- ------------ -- --------------- <br /> ------------------------------------ <br /> ---- <br /> -------- - - ------------------------------------------------------------------------------------- <br /> -------------------------Date ------ <br /> CFinal Inspection by: - f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 7-'68 Rev. 5M <br />