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-FOR OFFICE USE: <br /> 4PPLICATION FOR SANITATION PE:JT <br /> --------------------- -------- �' ....... <br /> (Complete in Triplicate) Permit No. -73-3. <br /> -- -- ---- ----------- - <br /> ------------------------------ This Permit Expires 1 Year From Date Issued <br /> From Date Issued �-Date Issued �F/ <br /> /73 <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/LOCATION2--Wiuz--ir---- -;-Cln.---.-..----..CENSUS TRACT --....-------------..-- <br /> Owner's Name -../�IsY L�G s-- ._�� ----------- - ------------------- .. ------.._Phone - -- -------------------- <br /> Address ------- --------- � �o- - ----- -- -- --------- ----------- City -------- ----------- ----a__ - ­------------------------------------ <br /> Contractor's Name ----- "l°------- --------------- - --------&&& - .License # - - -- - - ------- Phone ----------------------------- <br /> InsTallation will serve: Residence ❑Apartment House[] Commercial ❑Trailer Court <br /> Motel ❑Other ---._.._..-..------------------------ <br /> Number of living units:... ----- Number of bedrooms ---------..-Garbage Grinder ........_.. Lot Size - ---_--- - _-_------.--__r------------- <br /> Water Supply: Public System and name ---------_ --.-..-- ------ ---------------------------------------------------Private rR <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 [ ] SEPTIC TANK( ] Size---- ----------...-.___._---- .__.--._-. Liquid Depth -_-..---_•.__---..----. <br /> Capacity .---------- -.- Type -__-------- ------. Material---- No. Compartments <br /> Distance to nearest: Well ____.................___..--..Foundation __.___-.---..---- Prop. Line ---------------------- � <br /> LEACHING LINE [ ] No. of Lines ____...._...__. Length of each line______________ Total Length -----------._-.---.-------- C <br /> 'D' Box ..-_._.._ Type Filter Material -__---------------Depth Filter Material -- ---------------.---_--..----I........... G <br /> Distance to nearest: Well ._ -------------------- Foundation ________--___. Property Line -------------------_ _ <br /> SEEPAGE PIT [ ] Depth ..... _ Diameter ---------- Number __-_____-- -__.-- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth . ._........................---_.-_---......Rock Size ------------- --------------- <br /> Distance to nearest: Well -------.......Foundation --..-._--__------ Prop. Line --------- ............ F <br /> 0 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .--.---...-. ------.......-._--...--- ..... Date _--------------------------------) � <br /> Septic Tank (Specify Requirements) ---------------------..-.. - ----------------...--_. 'I- <br /> Disposal Field (Specify Requirements) ....../d;Zzl <br /> tet ---a .��.,..�--.------ <br /> -..-.. -- - ------ -- > -P ..t - Sr,� .-..5 <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 th performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be mes Ie t to Workm9s Com ensation laws of California." <br /> Signed _ ._ .- __,_ .._ .� . Owner <br /> By ......a- -------------- - .......... - - --- --------------- Title ... _..._...-. ------ - - . --------- -----.-..--.--- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------- - 0�`----------- ------ ----------------------- DATE ---- -�� -^�3............ <br /> BUILDINGPERMIT ISSUED -------------------------__------------------------- ---.... .... ----------------------.-DATE --------------------------------- <br /> ADDITIONAL COMMENTS ---------- --- --------------- -- - - ---------------. .------------ ---------------&aa------- <br /> ---------.--- ----- - ---------------------------------. . --------- - - ---- -----_---- - ---�- --- <br /> - - - - - --- ----- -- <br /> �J _ r - <br /> Final Inspection by: .L Dat <br /> - -- - --- --- ----- ------... _---- ----- a - e - - -- 1 `� <br /> - ' - - <br /> SAN JOAQ61N LOCAL H=ALTH DISTRICT /� <br /> E. H. 9 1-'68 Rev. 5M � <br />