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FOR OFFICE USE: w -� <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------- ----------------- ---- <br /> ___ k Permit No. <br /> (Complete in Triplicate} <br /> ----=---- --- -------------------------------------- i <br /> Data Issued <br /> ----- <br /> t This Permit Expires 1 Year From Date Issued <br /> ------- -------------------------------- w <br /> Application is hereby made to the San Joaquin Locak -iealth District for a permit to construct and install the work herein " <br /> described. This application 1f made in compliance with County Ordinance No. 549 and exist ng�Rules,�and Regulations: <br /> JOB ADDRESS/..LOCATION .' _� ---- '------ '' ----------- <br /> d7: -------- .--,-----CENSUS TRACT ------_- - <br /> I --_ -' -----=-==-------------------Phone.- - Lam- ------ <br /> ---------------------------------- <br /> Owner's Name - -- -�--�' --�t--� --:---�-�� �-��"° --------- <br /> Address ......1- TS-- ----- ---- e---------------------- City __r f <br /> Contractor's Name -- :, t'3r;'� fi�`�" rr� ' - -------.License #a?F? 5=0----- Phone ---------------------•-------- <br /> Installation will serve: Residence Apartment House-F-1 Commercial ❑Traile'r Court--,E] <br /> � . <br /> Vote ❑Other ---------------- ---------- ---- -- <br /> Number of living units:._/------- Number. of bedrooms - _-_--Garbage Grinder --.- Lot Size .. � - <br /> v . System an _namet -o--------------- t <br /> :-------------- Private <br /> _Water Supply: Public --------------- -. ----- <br /> Character <br /> of soil to a depth of 3 feet: �and'�Silt[DClay E] Peat E] Sandy Loam [] Clay Loam '❑ <br /> Hardpan ❑ Adobe ❑ Fill Material . Q___ !f yes, type ------------ <br /> (Plot <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 /> TREATMENT { ] SEPTIC TANK Size-- -� ��--66 .di-------- Liquid Depth -.--__ ------------ <br /> PACKAGE � <br /> Ca aci / _ T e ----___------- --- MaterialL"404 No. Compartments -- -...-----.-- <br /> Foundation _-- -----------. Pro Line ----- ---------------- <br /> once to nearest: Well --_-.. --------___---__---- �- P• <br /> LEACHING'LIN) "" ' 'No.'of Lines �_t Length of each line--.-_��------------- Total Length ---_.jam - ------- <br /> `- <br /> 'D' Box --/------- Type Filter Material -f Cnle,.-Depth Filter Material ------�-��------------------•- <br /> Distance to nearest: Well ____.�~ ---_.---.-- Foundation -..�. --------- -- Property Line - �---------------- <br /> SEEPAGE PIT [ ] Depth ---_-_---_--------- Diameter --------------_ Number ___-------.-----------. --- Rock Filled Yes ❑ No i0 <br /> Water Table Depth ------------------------------------------------Rock <br /> Size -------------------------------- <br /> Distance to nearest: Well ---------------------------------------Foundation ---------------.---- Prop. Line ---------_-____-.._.-- <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit#.-------------------.-------- ---------=------Date--------------------,-----------------1 <br /> Septic Tank (Specify Requirements) --- ------- ------- --------- ---------------- ------ <br /> Disposal Field (Specify Requirements)' `..'h'------� ----------------------------- ---------------------------- -------------------- ---------------- <br /> -_ +'--* <br /> - ------- ----------- --------- ------ <br /> -gid �— <br /> J <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,'a'nd Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the fllowing: <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 kman's Compensation laws of California.'.-' <br /> Signed �--- -�'�- :- �--------- - �- <br /> ------ - ------ -- /__ Owner <br /> / --------- - <br /> -�c -�f L Title <br /> ------- -------- <br /> (If other than oner) <br /> FOR PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---�t_-f- -----. DATE ---��-�L9-�_6y------=------- <br /> BUILDING PERMIT ISSUED -- ------- - ----- --------DATE ------------------------- - --------------- <br /> ---------- <br /> ADDITIONAL COMMENTS ------ -- ---------------- <br /> I ------------------------------------------ <br /> - <br /> ------------- <br /> ------------------ - --- -- - - -- ------------------------------------------ <br /> 1 ---- - ----- - ------ ------- � <br /> . ---- - ---- ------ ----------------- <br /> --�y <br /> Final Inspection - Date t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` E. H. 9 1-'68 Rev. 5M <br />