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FOR OFFICE USE: <br /> ,�. API'LICAPON FOR SANITATION PERMIT Permit ,&� <br /> - - (Complete in Triplicate) <br /> ---------- ----------------------------- -----------.- <br /> - Date Issued <br /> ---------------------_---- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Orrd'nanrre Na. 5_49 and existing Rules and Regulations: <br /> DC/S,C`.- / l/-_ f� . : ` -CENSUS TRAC --�`-------------------- <br /> DRESS/LOCATION � t <br /> JOB AD .-h�z`�SI -- -- . - - =_.._ <br /> Owner's Name ._ , / -Q- Q ------------------------"------------------------ ----=----------- Phone <br /> !? <br /> f <br /> Address ------ v6 / _ -7 <br /> Contractor's NameT ------------------------------- License #� Phone <br /> Installation will serve: Residence Z-Apartment House❑ Commercial :❑Traile'r Court °❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--../------ Number of bedrooms __3-----Garbage Grinder Nv----- Lot Size -300--------------- <br /> - <br /> Water Supply: Public System and name ------------------- ------------------ <br /> -----------------------------------------------------------=-------------Private _. <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat ❑. Sandy Loam ❑ Clay Loam ❑ j <br /> Hardpan ❑ Adobe [? --Fill Material ____ ------- If yes, type ---------------------------- <br /> 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK'[A--- Size----- �+'�r `1---------------- Liquid Depth --e!K.___.I----------- <br /> ; ' <br /> entsCapacity --- Type Material�'O o. Com artm <br /> WellS ` ---------------- --_Foundation -/CV--- -----. _ Prop, Line --- -------- <br /> Distance to nearest: 7 <br /> � r <br /> LEACHING LINE [4--No. of Lines .....;,Z.------------ Length of each line___. _ -____.___._- Total Length _f - -----=------- <br /> 'D' Box ----- Type Filter Material _1-OC/C-----Depth Filter Material __f_ __-_r____________________________ I� <br /> Distance to nearest: Well _.._=3`=G'-- ___-_-_ Foundation -------------- Property Line _________ <br /> SEEPAGE PIT [ =!" Depth Diameter ---a3------ Number ____-�_._._r__/___ [� 0-- Rock Filled Yes ' No <br /> Water Table Depth - - ----------------------------Rock Size ��-f ---------------- <br /> Distance to nearest: Well ._ _a C -----------------------..-Foundation --- Prop. Line --5---__-_.__.._ <br /> Date ------------------------------ -} <br /> ' REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- - <br /> 1 � <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------<"-------------------------•- I <br /> 1 <br /> Disposal Field (Specify Requirements) ---------------- -- ------------------------------------------------ i� <br /> ------------------------- <br /> ---------- ------------------- -------------------- <br /> ---------------- -------------------------------- ------------------------- <br /> -------------------- ---------------------------4-------------------- -- ------------------------------- -------------------------------------------- ----------------------------------------- <br /> (Draw existingand 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 O <br /> as to be com subject o Workman's Compensation laws of California." <br /> Signed __ . ' _ Owner <br /> BYTitle ---------- ------------------ <br /> ----- --------- ---- ----------------- <br /> llf other than owner) <br />` FOR DEPARTMENT USE ONLY <br /> ------- ------------------ DATE __---�.� _---------------------- <br /> APPUCATION ACCEPTED BY _-- -�------------------- ----------------------------- - <br /> BUILDINGPERMIT ISSUED ------- -------------------- ----DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------- --- --------------------------------- ------------- --------------------------------- --------- <br /> --------------------------- -------------- ------------- <br /> ------- ----I-------------------------------------------=------------------------------------------- <br /> ----------- -- ----------------------------------------------------------------------------------------------------------------------- -------- - <br /> ---------------------------- ----- ------ <br /> ---------------------------------------------------------------------------- -------- - - --- ----- - <br /> f <br /> Final Inspection by: - �'^,� -- ----Date ------ - .... - - ------- <br /> SAN JOA QUIN LOCAL HEALTH DISTRICT <br /> I E. H. 9 1•'68 Rev, 5M <br />