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FOR OFFICE USE: <br /> �a.PPLICATION FOR SANITATION PF,4IT <br /> r... - ........_.-.... . . <br /> (Complete in Triplicate) Permit No. -"-'-- -� <br /> ..-.._-._.-..........__...-.-... This Permit Expires I Year From Date Issued Date Issued <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 rdinance No. 549 and existing Rules and Regulations: <br /> L JOB ADDRESS/LOCATIO `f6.�la__-...------- ---------- --- .-_............._.....----------.......CENSUS TRACT <br /> �1 7.__. <br /> Owner's Name -------: -- -- - --. ..- =-- --------------------------------_..--_Phone V4--7--001f -... <br /> L, Address ---- Chyli----_--.__ City -- <br /> Contractor's Name ..... ------License # /00S//------- Phone .Z..�+.f0..-1.91.Q.7- <br /> Installation will serve: Residence KApartment House-E] Commercial ❑Trailer Court [] <br /> v Motel ❑ Other ------------............. ........... <br /> Number of living units:------/.._ Number of bedrooms ..... Grinder ------------ Lot Size ----- ........ <br /> r <br /> Water Supply: Public System and name ----------------------------------------------- ----------------------------------- ------_--------------Private <br /> ( <br /> Character of soil to a depth of 3 feet: Sand E] 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 .......................... 4 <br /> Capacity ..... Type -------------------- Material..............-.------ No. Compartments ...................... <br /> _ Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... C <br /> LEACHING LINE [ ] No. of Lines . ---------------------- Length of each line........................._. Tota[ 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 Q <br /> WaterTable Depth ...............---------------------------------Rock Size ------------------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------ ----_-.-_-_--_--_.-..---. Date ..................................) <br /> Septic Tank (Specify Requirements) ........ ....../..,-y--------..,-,1---------...._......------------.........-- ---------... <br /> Disposal Field (Specify Requirements) ..._(. .LA........J-.-l/-�- '4 's*'t�.--CL'+ /............. ................. <br /> -- --- -- - - -- ._....------ <br /> - -- - ...... P`------------ ----------- --------------------------------------- <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 /> L "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 Workman's Compensation laws of California." <br /> Signed -----....._. _- . - Owner <br /> r- --- <br /> L By / `1l -- -------- .._. Title ...... _. --- - _ _ _ _ _ ...._._.. <br /> (If other t owner) <br /> OR DEPARTMENT USE ONLY <br /> 1 <br /> ` APPLICATION ACCEPTED B c{- 7 ._ DAT r'y .. .. <br /> BUILDING PERMIT ISSUED - i[' __. DA <br /> ADDITIONAL COMMENTS <br /> L ...------------......_.-._....-------------------- ---.--------------...._...-------_....--._ -...._..------ ------......_...... - -- <br /> L - . ... - _ <br /> ..-- /--- - -- - -- ------ - - .._ -_..- --- - --- - r� -... . .. - <br /> -- <br /> Final Inspection by .._. �4.t--- L�.0-C. . . - <br /> __ ... Date _ /-.1. <br /> LSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />