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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - - - ��•-`-�� Permit No. _�I.._y_�-F76 <br /> (Complete in Triplicate) <br /> _ _________________________________. This Permit Expires 1 Year From Date Issued <br /> ______________ __ <br /> Date Issued <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 c npliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ------- CENSUS TRACT -.-__�?/.-------- <br /> Owner's Name .--��/ ��' i' �fi�----------------------------------------------------------------- ------.Phone <br /> � �= l -�t/IG fJ LY�C 4_. --- � -------------------- cit 10��E1 Ji{J---------------- ------------------- <br /> Address Y <br /> Contractor's Name b -----_.License # f%%.- �'-_- Phone '�1- ---- <br /> -------------------------------------------------------------- <br /> Installation will serve: Residence El-Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- _ <br /> Number of living units:---- ...... Number of bedrooms ._------Garbage Grinder _IL"u___ Lot Size _cz2f-_ ------------- <br /> Water Supply: Public System and name --- -----------------------------•---------------- -----------------------------------------------------------Private V1 -- <br /> Character of soil to a depth of 3 feet: Sand'C Silt❑ Gay ❑ Peat5�6 <br /> Sandy Loam E] Clay,Loam.E] <br /> Hardpan Z Adobe [:] Fill Material .__ If yes,type ----------------_---------_ (1� <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,j <br /> Q. <br /> PACKAGE TREATMENT [ I SEPTIC TANK f4— Size__%;Y XyV----------------------- Liquid Depth -___,_____ <br /> Capacity _/ a dLType�✓� __ Material_�_�_-`Xlf`r��� No. Compartments - _______________ <br /> Distance to nearest: Well _._ --------------------- -------------- Prop. Line _4----------------- <br /> LEACHING LINE No. of Lines -- ----�-------_-- Length of each fine---jl6�7___r_-------- Total Length �_ 'J_.r <br /> 'D' Box/-1� _ Type Filter Material 104- C_______Depth Filter Material -/_ - !__________________ __ <br /> Distance to nearest: Well ---C� __'________ Foundation _l_�__�_t---------- Property Line ___�._--____--.___- <br /> nn <br /> SEEPAGE PIT [ Depth Diameter __ ------- Number ---------- Rock Filled Yes �No l❑ <br /> Y Water Table Depth __. QLD------------------------ -------Rock Size --- ----------._.:.__ <br /> _Foundation - Proi <br /> Distance to nearest: Well ----��-�---- - - -------------- ---�-- - --- P• Line .._ -----•---•• -. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----_-_______k_____-___-__________) <br /> Septic Tank (Specify Requirements) ------------------- ------------------------------------------------ ---------------------------­•------------ ---- -------- <br /> Disposal Field (Specify Requirements) _______________ <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 Sart 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: x I .-T- <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 objet to orkm/'s Compensation laws of California." <br /> Signed - ------------------------------------------------------ Owner <br /> By ------------------------------------------------------------------------------------------------------- Title ----------------------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = -------------------------------------------------------------------------- DATE ---- 1 - ---------------- <br /> BUILDING PERMIT ISSUED . --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------- -------------------------------- ------------------------ <br /> --------------------------- <br /> --------------- -------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ------ <br /> -------------- ------------------------ ---------- --------------------------------------------------------------------------------------------------------------------------� <br /> -------------------------------- - - --- --- ----------------------------------------------------------------------------------------� <br /> Final Inspection by: --------------------------------- ----------- Date _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M », <br />