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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - --r�------------------- - --•----------- --------- Permit No. <br /> - - O,r (Complete in Triplicate) <br /> - .". --------------- <br /> ---------------­-------- -------------:--------------- <br /> ____________ ____________________________________________ This!'ermit Expires f Year From Date Issued <br /> Date Issued --Z--- ,'-7 L <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 /> JOB ADDRESS/LOCATION .--.-.----- _� -S____------ _-_ <br /> - - -- s� � ENSUS TRACT _._ <br /> -------------------- <br /> Owner's Nam./* --- `t.. ��✓�'�-V-- �u r.0���---------5'�}�T3 L a Phone �-�_�S`�-`t ..... <br /> _... <br /> Address ------7a 4 -- ---------------- <br /> . �CZ - --------. City <br /> --- -- -- <br /> C -- <br /> Contractor's Name _- -___ <br /> ���:.--------y ---�-�-�- ---------------------License #a2�.11�-� Phone <br /> Installation will serve: ResidenceAr-INpartment House-[] Commercial _]Trailer Court <br /> Motel ❑Other ---------------------------------------- <br /> Number <br /> ------------- -------------- -------- <br /> Number of living units:__- - Number of bedr oms c+r g � <br /> -- sr�-_--_Garbo a Grinder _ .- Lot Size - --- ---------­---­--- <br /> Water <br /> --------- ---- --- <br /> Water Supply: Public System and name -------:,,u <br /> _ -- ___ 6J <br /> •-- ---------------- ---------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> Hardpan ❑ Adobe [p' 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 /> Z, <br /> 40 JU <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] vr.S��S'izf------------------ Liquid Depth --------------------:-.... O <br /> Capacity --- ---- ----------- Type -------------------- Material- -------- No. Compartments ---------------- ---- p <br /> Distpnce to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .--------------------- <br /> Ir <br /> LEACHING <br /> -------- ------ <br /> LEACHING LINEZT f-"N'-o. OT nes ________________________ Length of each line--------------------------- Total Length -__---..--.--_----_-_-_-_.__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------- <br /> Distance <br /> -- - _ - <br /> Distance to nearest: Well ------------------------ Foundation ----.------------------- Property Line. -------.-.-------.--.--- <br /> SEEPAGE PIT Depth ---1?�_..--------_ Diameter 1!PkAo"� Number ----------/-------------- Rock Filled Yes & No 0 <br /> Water Table:Depth ------ --------------------------------Rock Size ----1-12--1------------------- <br /> Distance to nearest: Well ------- )W�--C_c Al -....Foundation ------- Prop. Line A----_.--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit x# -------------------------------------------- Date --------.---------------------_.._) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------•-- <br /> Disposal Field (Specify Requirements) ------ _--__ __---, U --: - _-- 1___ <br /> --------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------•-------- <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, 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 /> By --- -- -------------- 7. ------------- Title ---------�---- ------ '�------------------------- <br /> (l{ other ffian owner) �OE <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- -------------------------------------------------------- DATE ....2.77*- <br /> BUILDING PERMIT ISSUED --__- <br /> - - --- - --- -- --------------- -------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL + <br /> COMMENTS ------- - <br /> ----------------- ----------------------------------------------- --- ---------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- - - <br /> Final Inspection by: -------------------------------- ------.Date ---- -/-�'------- ---- �y <br /> -- - - ------------------------ <br /> AN AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />