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d CCFOR OFFICE USE: /_ APPLICATION FOR SANITATION PERMIT ��� <br /> --------- <br /> F! 7 -1---7-- - - ri (Complete in Triplicate) Permit No.�Q-------------- <br /> - <br /> ---- -- - ------ -------- <br /> _ This Permit Expires 1 Year From Date Issued Date Issued .4-- �_-.. <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 /> F12C1Y t <br /> ,� ,y 9 ' ENSUS TRACT L JOB ADDRESS/LOCATIOtAXA41 ---. - ---OY /',tii�l � - --0[!✓-- �f---� r3s CT ------- <br /> Owner's Name ..Refl1givi{..--- L...--- -BLLUl'ALL-.._--------"------------------Phone ------------------------------- <br /> Address ---------------'--------------/------------'---------- ---------`-------_.----------- City -5716cm---------'----------------------------------------------- <br /> L Contractor's Name -- Z o ��/ ------ -----------------------License #�.�c�i�orf_ Phone j�P_:3_'L?SVX. <br /> Installation will serve: Residence ❑Apartment House <br /> E] Commercial❑Trailer Court <br /> Motel ❑Other _ / ------------.--- <br /> Ut <br /> Number of living units:-----------. Number of bedrooms ..__._.._...Garbage Grinder ..-. --- Lot Size d#_ lL _F z -.____.__......_- J <br /> Water Supply: Public System and name ----- -----------------------------------.- Private$ (� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat[I Sandy Loam ]] Clay Loam 0 <br /> Hardpan ❑ Adobe F Fill Material -_-. -- If yes, type _.__-..__._--___.___. p <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 /> At <br /> PACKAGE TREATMENT [ ] SEPTIC TAS [ ] Size.__. '. -ea.X._�_a Liquid Depth .�f __--_.._._ <br /> Capacity A5_0 _._._ Type . _4Material---00 t:_�_b-,9.`�No. Compartments --- .____...__.- <br /> i <br /> Distance to nearest: Well ----67V-/----------------- ...Fouriclation --------- Prop. Line - <br /> LEACHING LINE [ ] No. of Lines R----- Length !o!fd1 �each line_.-______- Total Length ._f_7P--.-.._-.-_- <br /> 'D' Box ._._------- Type Filter Material ICd24f ._.__-Depth Filter Material ._/ '��_..__..--. ---._............. � <br /> i Tof <br /> Distance to nearest: Well ----c7-f--------- Foundation __!d--- --------- Property Line .6.. .............. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -3-i-------- Number ..._....�-- ----------- Rock Filled Yes [j No C3 <br /> Water Table Depth -------- ......... - ---------------Rock Size -------------------------------- ' <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- ___ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .____- ------------ Date ---.__....--------.____.__.___- <br /> Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------------------------- ------.--------------- <br /> DisposalField (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 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 become subject to Workman's Compensation laws of California." <br /> Signed _ _. -..- w ----------------------------------- Owner <br /> BY - -GL:�C�/j -�. - _-._ Title ----- __..- -------- ----------- -------- <br /> .. - - <br /> (If other than owns' <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- _- ( .- _ __ DATE I <br /> BUILDING PERMIT ISSUED -------------------------------- ._. ._. DATE ------------........._. __. . .-- <br /> ADDITIONALCOMMENTS.- ------- ------------------------------------------------------------------------ - ------- ---------­--------------------------------- <br /> - - ---- -------------------------------- ---------------------------------------------------------------- -- ---- ---- -------------------------.---- - <br /> -- ------------ --- - ----------- -----` ----------------------------------------- -------- - - ----------------- ------ -- - --- -- ------- <br /> .. .... .. - I <br /> Final Inspection by: ..----t..-- ....-- ------ ------------------------Date ----- --' -------- -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />