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k <br /> FOR OFFICE USE: <br /> ,� APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------ - ------------ <br /> (Complete in Triplicate) Permit No: .7 <br /> __ _ _________________ This Permit Expires 1 Year From Date Issued Date Issued ._..________I_____. <br /> --------------o "� C�/_," s [S9--r2o <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 <br /> , with County Ordinance No. 5.4�existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ -_ -___-- _ --Y.�l�sI 'y` � --- - -. CENSUS TRACT -------------------------- <br /> ---- <br /> ---� _. <br /> Owner'sN me - = ? ----------------------------- - <br /> ------------------Phone �-3 -- <br /> Address <br /> -- ----- ----------------- <br /> -- -- ---------•--..... City ----� ,lfL 'C <br /> ------------ <br /> Contractor's Name ------ a _ _� --------License # _-�_ /.__T_3_._ Phone - 7 <br /> Installation will serve: JResidence ❑ Apartment ouse❑ Commercial ❑Trailer Court ❑ <br /> /P_ <br /> . Motel ❑ Other -- _��_��__�_�_--L--�! ---- 3_0 <br /> Number of living units_____________ Number of bedrooms ...---------Garbage Grinder ____________ Lot Size -.�. __ ---------------- <br /> Water <br /> _____________Water Supply: Public System and name ------------------------ -------- ---------- ---- -----------------------------------------------------------Private]' <br /> Character of sail to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ 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,) / 1.; ? <br /> r _f �. <br /> PACKAGE TREATMENT [ SEPTIC TANK' ize-7--� _ __ ______._ Liquid Depth _.._ _________,___. <br /> ,,•.,�- <br /> ' 1 _ Materia1L_ � `�i; No. Compartments __:- f <br /> Capacity- ---- =�-�--- TYPe�-�- /- � - -- ---- - ------•- <br /> �f,G Distance to nearest: Wel! ___ `_ __ /6 Prop. Line J.._/� ? <br /> FI ' ----------Foundation -/ -------- <br /> LEACHING LINE No. of Lines ------------------------ Length of ea line_,�G_ S<!"_ Total Length �r - <br /> r <br /> `D' Box __/.____. Type Filter Material '�l• ) ��� ---Depfih Filter Material <br /> Distance to nearest: Well ------- Foundation __/___-_------------- Property Line �� ` `.____ <br /> ' <br /> SEEPAGE PIV Water Table Depth Diameter--------------------Number �❑ <br /> Rock Size -_--_----.------Rock Filled Yes No ' . <br /> Depth p ❑ , <br /> Distance to nearest: Well '----------------------------------------Foundation -------------------- Prop. Line --- ----­------ <br /> REPAIR/ADDITION <br /> Date <br /> Tank (Specify Requirement Permit#------ - <br /> -------------- --------- --- -_ <br /> Septic <br /> c -----------------------------------'---------.--------------- •----------- <br /> Disposal Field (Specify Requirements) __________ __ ____ <br /> 4 f ii <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 i <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: f <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 beco ,subi 'ct to W "kma s'Compensation laws of California." <br /> 5 <br /> Signed --- ` ( �`� L �{°� -- ------ Owner <br /> BY ------------------- --- -- U - - - <br /> ----------------------- Title ----------------- --------------- --------------------- <br /> (if other an ow er) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -- J DATE � y------------- <br /> BUILDING PERMIT lSSUI=D -- /- ----------- ----------------------------------------------DATE --------- --- ----------------------------- <br /> ADDITIONAL COMMENTS ----- - ---- ----------- - - - - - <br /> ------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------- ----------------- ---------------------------- <br /> - --------------------- -- ---- ------------------------------------- -- ----- <br /> Final Inspection b � - - -------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev- 5M <br />