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FOR OFFICE USE, APPLICATION ON FOR SANITATION PERMITPermit No. <br /> (Complete in Triplicate) <br /> ------'-----------'-------------------------- <br /> ---------„--- This Permit Expires 1 Year From Date Issued Date Issued __S............... <br /> Application <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> Ldescribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> LJOB ADDRESS/LOCATION L.3 7- ---�---1 �-----y GCI- ---- --- - --------------- --CENSUS TRA/CT ---'---n-------------- <br /> Owner's Name Q ll. ./k --_ICJ�d(;A5-� L%./ � `2_ _ .-.. PhonelChLS-----7 7_ - <br /> ? L <br /> L Address .3.,J---7-Z----""-5-------------- - •- --I--e/--:--/- - _ City -- !_DC' --------------_-_------_-_..------ <br /> Contractor's Name ---- -.f---'-- 1Z.G�1./--- ------------- -----..License # ----------------------- Phone <br /> 4 L <br /> InstallatiS2�vill serve: Residence E]Apartment House-[]House-[] Commercial❑Trailer Court <br /> Motel ❑Other __... U_ .a/2_._�.e my/ <br /> Number of living units:----------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---@5�fe! --- - --.----- <br /> Water Supply: Public System and name -------------------------- -------------------------- ---------------------------'-------------------Private [� <br /> Character of soil To aaiep$of 3 feet: Sand I_] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam[] C <br /> Hardpan ❑ Adobes" Fill Material . ---------- If yes, type ----------- ---------------- <br /> V <br /> r / __ U <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,) L \ <br /> PACKAGE TREATMENT I ] SEPTIC TANK[ ] Size__- c`�`_ -— _r�L-.---_ - Depth X11-------._.-.-.... <br /> Capacity c2V0G-_ Type/R�_q94 MaterialNo. Compartments ._-______---------- <br /> Distance to nearest: Well __---------------_---------Fbwidation _L.G_.____._.___ Prop. Line -�_-_.//_:._...-. <br /> r LEACHING LINE [ ] No. of Lines __-�___--------- Length of each ne _ _ --'---70. Total Length 71 <br /> D' Box ------------ Type Filter Materialp <br /> De th filter Material ............................. <br /> Distance to nearest: Well . n_�.___-__ Foundation ..._.__� Property <br /> �� - ...._.._ Pro Line ��--- ------------•---- <br /> SEEPAGE PIT [ ] Depth 247_-------- Diameter 33--------- Number ___�.____.._ _.------ Rock Filled Yes ff No [ <br /> Water Table Depth -----------------------------........------Rock Size . �� ........... <br /> r / .------ ............Foundation 16--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit;# .--------_._...----------------------------- Date -----------------.-----_-___) <br /> b. Septic Tank (Specify Requirements) ---------_---------------- --------------------------------------------- .----------------.-... --- ---. <br /> Disposal Field (Specify Requirements) 'l= ---------------------I----------- --------- ---- ----------------------------------------- <br /> ------------- <br /> ------------ ------------------------------------------------------------- ------------- ----- ----------------------------------------- -------- <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 ---...- -- ----- . -------- <br /> -.--- Owner <br /> By --------- - - - - - '- . -------------- Title -_. - - -------- <br /> (If other than owner) / <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / --------------------------------------- - DATE ----5 a -1-H-- ------------ <br /> BUILDING PERMIT ISSUED .---- <br /> - - - - - -DATE - -------------------- - <br /> ADDITIONAL COMMENTS ------------_-------- ---------_.---- ------------------------------------------- ----------------------------- ---------_. <br /> -------------- - <br /> -------------------------------------------------------------------------------------- ------------------- -------------------------------- -­---------------- -'------- <br /> - _. .. --------------- <br /> Final Inspection by: ----'------ --- - --- --------------------------------.Date -----''�-- - ..... <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />