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FOR OFf1 CE USE: APPLICATION FOR SANITATION <br /> Permit No. <br /> ------ ------------------------------------------------ <br /> (Complete in Triplicate) <br /> =----------- p <br /> Date Issued __�_��~ / <br /> This Permit Expires 1 Year From Date Issued <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 __ __J-- - ---,- - ' N ------R o-ad-----------CENSUS TRACT -------------- ----------- <br /> Owner's <br /> -------- ---------------- <br /> Owner's Name ----A_F1_—f4,CJ--A----M_4-4­0---------------------- ------- -Phone > - -3a�I-_------ <br /> Address . _� — -��--e -" <br /> City _ ----------------------------------------- <br /> Contractor's Name ----�!Y�-kt_�/_ ----�a 'r�G- -11�iy11 ---- 1� -------License # .� : 5!--- Phone6_ <br /> Installation will serve: Residence [Be partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other _____ , <br /> --- `r <br /> ______ ____________________________ fes_ <br /> Number of living units:---- ----- Number of bedrooms 9.----- Grinder.-'C7------- Lot Size -. --L' - - -� T <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------------- Private ]� J <br /> Character of soil to a depth of 3 feet: 5and!�Silt[] ClayO�r..Peat Sandy Loam ❑ Clay Loam :❑ <br /> Hard pa Adobe F7] Fill Material' ----------- If yes, type ------------- - ------------ <br /> (Plot plan, showing size of lot, location of "systemJn' relation tc wells, buildings, etc.,,must_be placed' on reverse side.) <br /> .-� v_ <br /> 57 <br /> NEW INSTALLATION: (No septic tank or seepage pit per if public sewer'is`a�Tailable within 200 f8et,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[] Sizes`--------- ---------------------L ,,, -'Liquid Depth ----------:----------.-----M.s�.. -;�--..- <br /> Capacity.--------------- Type -------------------- Material No. Compartments <br /> ----Foundation ------ --------------- Pra Line ----•--------_--- <br /> FDistance- to nearest: Well _______.-______-_��-_,____ ,p� -- <br /> LEACHING LINE [ I No. of Lines ------------------------ Length of Each line--------------- ------ Total Lengfli ------------.--------------- <br /> Ix <br /> D' Box ----------- Type Filter Materia51 ---- ------------Depth Filter Material -------- ------•--------=- <br /> ! Distance4c, nearest: Well -------- -------- Foundation ------- ---------------- Properf1 Line --------------------_- <br /> - <br /> ___ Number ____________________________ Rock Filled Yes ❑ No 0 - <br /> SEEPAGE PIT [ ] Depth ---'--- -------- <br /> '-- Diameter --------• -- <br /> i Water Table Depth ----------------------------------------------- Rock Size ---------- <br /> T <br /> Distance to nearest: Weil ------ ------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> I <br /> ' REPAIR/ADDITION(Prev. Sanitation Permit�# -------7!----------------j------------------ pat --------------------------- --- } _ <br /> Septic Tank {Specify Requirements} ___ .cw_ 7-p Q----;_ <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.,.Joatluin•.y, <br /> County Ordinances, State Laws,land 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 /> X as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------------------------'------------------------------------------ Owner <br /> ----------------------- ------------------------------ Title -- c ! -- - -------------- - ------------------------------ <br /> (if other that owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION-ACCEPTED BY -- c �i- -------------------------------=----------------------------- - DATE -_nZ."- - /------------------- <br /> BUILDING PERMIT ISSUED -------t--------- ---------------- <br /> -------DATE ------- ----------------------------------- <br /> ADDITIONAL COMMENTS -------------------------- ---------- ---------------------- "-------------------------- <br /> ----------------------------------------------------------------------- - <br /> ------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------- ----- ---------- ------ ----- ----- "-------- <br /> ---------------------------------------- --- ----- -- <br /> Final Inspection by: <br /> ��-'�--- ------------ �--------------- ----------------------------- __. ------------ - -----Date --------------- ----------- <br /> - <br /> .SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />