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FOR OFFICE USE: <br /> a � 70 APPLICATION FOR SANITATION PERMIT <br /> Permit No. _A._�� --__ <br /> a (Complete in Triplicate) <br /> ---------------- _ _ - --__ This Permit Expires 1 Year From Date Issued Date Issued -. --/-o- v <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION � -- l .Ty `5 ------- ----------------CENSUS TRACT -------------------------- <br /> Owner's Name ....... /t1��l�f ---------------------------------------------=- ------ ------------Phone -- ------------------------------- <br /> Address ---- --- /' LG1P1 ----------------------------- <br /> Contractor's Name .- /�` S'.--_ l�T/�____� /P �C -------- -------License # --.- Phone __7IKV=a-.23-_ <br /> Installation will serve: Residence [ 'Apartment House,[-] Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ----------------- -------------------------- <br /> Number of living units:.-_ ------ Number of bedrooms --,;2 -----Garbage Grinder _A1_0_- Lot Size _---------------- <br /> Water Supply: Public System and name --------------------------------- --- ----------------------- ------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] <br /> Hardpan ❑ Adobe X 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:{ ] Size------------------------------------------------ Liquid Depth ---------------------.----- lZ <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------•-=---- AAl <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------_ ........... <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of each fine---------------------------- Total Length .-----------.._..------------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------.---_.---__.-_---------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -----------------_---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No 0 ` <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- ` <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------_---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------.----------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------- ----------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) Q - Gh'-- / 4. -�----------------------- <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 becom su t to Workman's Compensation laws of California." <br /> Signed -------------------- Owner <br /> By --------------------------------------------------------------------- ----------------------------- -Title -------- -------------------------------------------------------------- <br /> (If other than owner) OOR <br /> .DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------- DATE ------- U ------- <br /> BUILDING PERMIT ISSUED ------------------------------------- ---------------- ----------------------------------DATE ---- -- ------------------ -- <br /> ----------------- - ----------- <br /> ADDITIONAL COMMENTS -------------------------------------- -------------------------------------------------------------- ---------------------------=--------------------------- <br /> ------------------------- ------ -------------------------------------------- ------------ <br /> ----------------------------------Date ----- C `- ------------ <br /> --- --- - - -- - <br /> Final Inspection by: �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />