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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: ___.------------------ <br /> --------- - """"-------------------- ----------------- 4 - (Complete in Triplicate) <br /> --------------------------- - -7,F-,72 <br /> -------- -- - ----- Date Issued _. --------------- <br /> This <br /> �. T-------- - <br /> ---------------------------- <br /> This Permit Expires 1 Year From Date Issued <br /> I Application is hereby made to the San Joaquin Local Health District for a permit to consteuct and install the work herein <br /> ' described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ra 1 r c-- -----CENSUS TRACT ----- ------ ----------- <br /> JOB ADDRESS/LOCATION .-----q----- -------:- �ra_ ---G� <br /> I - /1 Phone _.-��S'g���----- <br /> Owner's Name ........... <br /> ---- -----cd-,I�C'_h-------LAOS �t-------------------- ------------------ ----------------------------- <br /> Address 5�`�"` ------------------------------- City ----------------------------------------------------------•-----"--- <br /> ----------------------------------- <br /> Contractor's Name 6 Day`@' ------License # --------------- ---- Phone ------------------------------ <br /> Installation will serve: R sidence'�Apartment House'❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑ Other ------ ------------------ ------------------ <br /> Number of living units:-.--�"" -- Number of bedrooms ------------Garbage Grinder ----------- Lot Size ---------- <br /> Water Supply: Public System and name ------------------ Private <br /> Character of soil to a depth of 3 feet: Sand'El Silt❑ Clay,F] , 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 /> SEPTIC TANK' t Size " Liquid Depth ---- ---------- <br /> PACKAGE TREATMENT [ ] [ ] _"� ------------"-"" <br /> LS <br /> Capacity -------- No. Corn t <br /> artmens ---------------------- <br /> I P Y ------- --------- Type ----- ----------- Material-------- ---- p 9 <br /> I '--------Foundation ------------------- Prop. Line ------------ <br /> Distance to nearest: Well ____________________________ /---------- <br /> LEACHING LINE No. of Lines -------------I-__-----_ Length of each line-_..__ / 0--.------ Total Length -____....1"' ---------- <br /> a <br /> 'D' Box ------------ Type Filter Material --r4A "______Depth Filter Material _.___-/9-___-------------------------- <br /> ,. - <br /> -- _ lQ Property Line <br /> Distance to nearest: We11 _ ';? '�7_--"---- Foundation _- <br /> t <br /> SEEPAGE PIT [ ] Depth ---------- --------- Diameter---i-------------- Number ---------------------------- Rock Filled Yes E] No <br /> f <br /> Water Table Depth ______Rock Size .___--"""--------------------- <br /> i Foundation ---__ Pro Line -------------------- - <br /> Distance to nearest: Well -------} ---------- ------------- --- - ----------- p• �. <br /> F REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------•------ } <br /> - . --------- <br /> Septic Tank (Specify Requirements) =----------- -- :` <br /> ------ <br /> f <br /> t F <br /> Disposal" Fi`1d'(Specify Requirements) -------- <br /> a <br /> ------ z-----�Q--- .�.,�- <br /> t ------------------- - -------------------------------------------------------------------------------- <br /> 7------------- ------- -------------------------------- <br /> I t ----------------------------------- ----------------- <br /> = ---------------------- <br /> (Draw exWing.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 Owner <br /> a <br /> -------------- ----------- Title ---------------- ---------- --------- ---- ;- <br /> - ---------------------------=--------------- <br /> (If other than owner) <br /> FOR DEPA#tMENT USE ONLY .21 <br /> APPLICATION ACCEPTED BY DATE -.-._.� <br /> -------- - ------------------ ---- --- <br /> BUILDING PERMIT ISSUED ---- €-`----------- ------ -- - ----------- - DATE <br /> ADDITIONAL COMMENTS ----- --------------- <br /> ------------------------------------------------------------------ <br /> ----------------------------------------------------------------- <br /> -------------- --- ----------------------------------------------- ------------ 5 ---------------------------"^_- ---�----- ------------------------------ <br /> -------- ---- <br /> ------------------------------ ------ <br /> ` -- <br /> Final Inspection bDate -� rl.� <br /> ----- -------- <br /> q1_U1--- <br /> SAN <br /> - ------------------------ <br /> p Y <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> u <br /> E. H. 9 1-'68 Rev. 5M <br />