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FOR OFFICE USE: <br />PLICATION FOR SANITATION PER <br />(Complete in Triplicate) <br />This Permit Expires 1 Year From Date Issued <br />Permit No.7.3y.••- <br />Date Issued .. /t'.:.%J.... <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 existi,�,p Rules and Regulations: <br />JOB ADDRESS/LOCATION .-LJ. .. ? rte+ ' -�'?'-Lo,d•�c'... j!'Li �s �'� - ___-.-...-CENSUS TRACT <br />Owner's Name ....................................................... ----- ------.Phone ----------------•------------------- <br />Address/__. .e e4,74Z.49 ay..(341 ................. -............................ Cityg... ..................................................... <br />Contractor's Name . � :. *- ✓�'`T.cc .lG�� - ..-f------..License # ....y.3,�h! �� Phone <br />v <br />Installation will serve: Residence ❑ Apartment House -❑ Commercial Elfrailer Court ;❑ <br />Motel ❑ Other -------------------------------------------- <br />Number of living units :............ Number of bedrooms ...::__:_..Garbage Grinder ............ Lot Size •----_----------•_ ---•-------------------•- <br />Water Supply: Public System and name .................-------.................................................... Private Q� <br />Character of soil to a depth of 3 feet: Sand LW 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,) <br />PACKAGE TREATMENT [ ] SEPTIC TANK 1 ] Size ................................................ Liquid Depth .......................... <br />Capacity ------•--•-------•-• Type .................... Material ...................... No. Compartments ---------------------- <br />Distance to nearest: Well....................................Foundation ...................... Prop. Line ----•------------•---- <br />LEACHING LINE [ ] No. of Lines ........................ Length of each line ........ _................... Total Length ............................ <br />'D' Box ............ Type Filter Material -------- _----------- Depth Filter Material ............................................ <br />Distance to nearest: Well ........................ Foundation ........................ -Property Line ------------------------ <br />SEEPAGE PIT [ J Depth .................... Diameter ------------•--- Number ............................ Rock Filled Yes ❑ No <br />WaterTable Depth ------------------------------------------------Rock Size ................................ <br />Distance to nearest: Well.•......................................Foundation .................... Prop. Line ------------------_--- <br />REPAIR/ADDITION (Prev. Sanitation Permit #............................................ Date ----------------------------------) <br />Septic Tank (Specify Requirements) ---_. ------------�----------------------------------_ -----.................. <br />Disposal Field (Specify Requirements) � .�z�-._.... X/!i�%---"-�i.G- - -------------------------------------------- <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 />Sianed Owner <br />BY -t �• � { ..._...._ Titfe <br />(If other than owners <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY .-•----...�� .:..-------. .---......................................................... DATE ..... ...'...?/ .............. <br />BUILDINGPERMIT ISSUED------------------...................................................................................... DATE ------------------------------------------- <br />ADDITIONALCOMMENTS----------------............................................................................................................................................. <br />•-••-••--•••••-•-•••------•-•------•-----••......... _.................................................................................................................................................... <br />--...................................................................................................................................... --•---...•••-----•----------•-•-------•---•-•..............••---- <br />Final Inspection by: ............ ...e:.. .ter-- -----••-----------•---......... <br />................................. ----- Date - r -••-------•-•• ....... <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E H. 9 1-'68 Rev. 5M <br />