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FOR OFFICE USE: APPLICAM{Complete in Triplicate}N FOR SANITATION PEf IT <br /> ----------- ----------------------------------------- <br /> --------------------------------------- Permit No;„ _,S_.1'..../----- <br /> ------------- -- --- -------------- <br /> ----- <br /> ------------ <br /> -- -- --------"--- This Permit Expires 1 Year From Date Issued Date Issued ....,.:.,._1.: ..> <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 rNo. 549 and existing Rules and Regulations: <br /> r v <br /> f / � 1 `�rt+ ._CENSUS TRACT ----------- <br /> JOB ADDRESS/LOCATION .---_------ ----- �..---.__--- <br /> Owner's Name - ----------�iii'L-- ---- 1 Ct _y' �---------------------------------------------------------------Phone <br /> - • � <br /> ------- <br /> Address ------------ --� �---------------------------------------------------------- Cit <br /> ------------------------------------- <br /> Contractor's <br /> ----- -------------- ------•-•---•-- <br /> Contractor's Name ----------------------------------------------------------- ---------- ----- one <br /> License Ph <br /> # ��- �� <br /> Installation will serve: Residence Dd Apartment blouse ❑ Commercial ❑Trailer Court 0 <br /> i Motel ❑Other ______________ <br /> ' Number of living units:_... ..... Number of bedrooms ___._____._Garbage Grinder ---_---.._- Lot Size -__.___._ <br /> �t Water Supply: Public System and name ----------------------------------•------------I----------------------=------------------------------------ ---Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt 0 Clay 54 Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material -- --------- If yes, type _"---"-------'--------------- <br /> F11 <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,) fr <br /> t PACKAGE TREATMENT [ ] SEPTIC TANK <br /> j d Depth __ <br /> _� -------------- <br /> Capacity <br /> ___.._______ <br /> Ca acctY - Type nts ---artme <br /> Distance to nearest:'Well ------ --------------------- <br /> Foundation _A---------------- Prop. Line.-_----__-_____ Q' <br /> LEACHING LINE [ ] No. of Lines ____,37 -------- Length of each line-----; ______________ Total Length _. C°_____________ <br /> 'D' Box -----/----- Type Filter Material l ' /{_Depth Filter Material __. T_ <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property. Line ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number _.------ Rock Filled Yes ❑ No 'C3 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------"--- G <br /> R <br /> Distance to nearest: Well ----------------------------------------Foundation --------------_.- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______________________________________ a <br /> e ---------------------------------- <br /> Septic <br /> ________________________.__-____Se tic Tank (Specify Requirements) ) <br /> - .----------------------------- '! <br /> E <br /> Disposal Field (Specify Requirements) ---------------------------------- ---------------------- ------------------------------------- -- --------------- <br /> -- ---------------------- <br /> ---- ---------------------------------------- -----------=-------------------`--------- ------------------ ------------------------------- <br /> ---- <br /> - ---------------------------__------_______________________________ __________________________________________-_____-__________._________-_.____.______________________----------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this appifcation and that the work;:*411 be done in accordance with San Joaquin <br /> 111 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. . o an's C4,o pensation laws of California.” <br /> J <br /> I Signed - 1 : - G `i'''-' ------------- OW <br /> wns <br /> �'G ----- - --------- <br /> BY - ---------------------------- Title ..---------------- <br /> - - -----------------------------=------ <br /> F1 <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-gY ------------------------------------------ <br /> ---------- --==--- _-----_----- _ =:. __ _ = DATE_ = <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------;------------------ -- ----------------------DATE <br /> ADDITIONAL COMMENTS --------------------- ---- --- -------------------=--------=-------------------------. -` <br /> ----- ------------------------------ ------ -------------------- = - <br /> ----------------------- ----- ---- ---- -------------------------- -- ------ --- ----- ---- -- - - ----- - _ __ ------------ -------- <br /> -------------- <br /> --- - <br /> --- - <br /> Final Inspection by: <br /> ------ - ------------------------------------------------- --- -------- - --Date -- -- "--- - --------------- -- <br /> IL <br /> SAN JOAQUIN LOCAL HEALT STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />