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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> o $- (Complete in Triplicate) b Permit No. -- -" 11'-. <br /> - ----- - <br /> Date issued /p'S�__�� <br /> ----_---------_I This Permit Expires 1 Year From 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 Ordinance No 549 and existing Rules and Regulations- <br /> ------- <br /> - ----- <br /> ---- <br /> JOB ADUVESS%LOCATION - <br /> t <br /> Owner's Name ---- ---------------------- - <br /> ------Phone ,tf6 - 7.701------- <br /> Address _E'1 CQ --------------------- City - <br /> Contractor's Name ----- � � - � - �- Phone ��'7�.� <br /> - License # _ �d _Q <br /> Installation will serve: �1„ Residence 0 Apartment House❑ Commercial ❑Trailer Court l❑ <br /> r Motel ❑ Other ----------------------------------- -------- <br /> Number of living units------ Number of bedrooms ___.__Garbage Grinder _.__r-_ Lot Size ____ -� r- ��� <br /> Water Supply: Public System and.name ---------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> hardpan Adobe [,y"_Fill-Maferial ___________ If yes,type <br /> 4 <br /> (Plot plan, showing size.of lot, location of system in relation to we'lis, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: -JNo 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 D6 No. of Lines- _._____ -__-_----- Length of each line____-__, _V---r-.-__ Total Length ___ __�_________ <br /> f; r I fi <br /> 1 , ------ Depth Filter Myat�erial ------ ----------- <br /> 'D' TYPe Filter Material -------- <br /> Distance -r--- <br /> •-.----- <br /> to nearest: Well ______4^ ____-__ Foundation ----___�r .___.___ Property Line <br /> SE41AA SIT [ ] Depth ___ -iQ-------- Diameter _ _ _ Number ______ ____________________ Rock Filled Yes ®' No <br /> Wate'r�T b Depth -------------------- �--e------=-----•---Rock Size ------- -r------------ i <br /> Distance to nearest: Well - ------- ------------------Foundation .—CO-4------ Prop. Line _./+ .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.------------_-.----------I <br /> Septic Tank (Specify R'quirements) ----------------------------- ------------------ - <br /> -------------------•------------ ---------------------------•----------------------------- <br /> - <br /> Disposal Field.(Specify Requirements) ------- -�____-- ..... ------------------ <br /> ,/ yf/ /'J <br /> s '` --------------------------------------------------fT`rf D--- f C.l-------------------------------------=------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------- <br /> ` (Draw existing and required addition on reverse side) <br /> 1 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. dome owner or licen- <br /> sed agents signaturecertifie's the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- - ---- ---- ---- ----- ------------------------------------ Owner <br /> ---------- <br /> BY -------� ----- <br /> (if <br /> --- - Title J <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------ -------------------------------------------------------------------------. DATE ----1D - - � " <br /> BUiLDIN.G__P-ERMIT_ISSUED ---�---------- --------------------------_-_------ ..--=_--,. - _---- -- --- _DATE_,. -----�__=----_--.--.-::----------------- <br /> ADDITIONAL COMMENTS `~ -----=------`-`----------------------------------- <br /> --------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ------------- <br /> ----------•--- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> ------------------------------------------ ---- - ---- - - --------------- - <br /> Final Inspection by: ____-- "____ _____ Date _.-_ - ----- ----------- <br /> ---------------------------------------------------------------------------------------------- <br /> SAN <br /> -- -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 9 1-'68 Rev. 5M <br />