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fi <br /> FOR OFFICE USE: Y <br /> APPLICATION FOR SANITATION PERMIT Permit No. o <br /> (Complete in Triplicate) <br /> ----------I--------------------------------------------- <br /> Date Issued 70 <br /> -----------------------------------------_--------------- This Permit Expires 1 Year From Date Issued <br /> _5__�l�' <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - // - �t�_ ---------------------CENSUS TRACT ----------------------.__-- <br /> Owner's Name ---/7lo w4 ------ ------------------------------------------------------ ----------Phone •---- <br /> Address _1City --Q C /Q11d---------------- -------- <br /> --- <br /> Contractor's Name ---/7- p_j9d✓ ----'_'�17A�' r ------- --------License. -•�a G__ Phone <br /> Installation will serve- Residence [4�Kp­artment House-El Commercial '❑Trailer Court ,❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units----/------ Number of bedrooms ______Garbage Grinder _ Lot Size ___/-_ ----Ae"11:e------------- <br /> Water <br /> _-_----_.Water Supply: Public System and name ------------------------------------------------------------- -------------------------------------------------Private er <br /> Character of soil to a depth of 3 feet: Sand'El Silt o 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 seepa a pit permitted if public sewer �available within 200 feet,) <br /> �'� �yy .V �� 0. <br /> PACKAGE TREATMENT [ ) SEPTIC TANK;[? Size4%� _.X---/__ .__x�1____. Liquid Depth - --------------------- <br /> Capacity <br /> ------------ ---- <br /> Capacity/.i:.-V49.--------- TypeA1F_74 PA6_ Materiala-*C 7Yoe' No. Compartments _ __.. W <br /> .......... <br /> iP 4e s W <br /> Distance to nearest: Well _ --------------------------Foundation _/0-------------- Prop. Line _ -_.._.:..__..-_ <br /> LEACHING LINE [kr' No. of Lines --,gZ--------------- Length of each line___ __------------- Total Length /_9 ............. <br /> Box ___ __ Type Fitter Material/ Q_��� ______Depth Filter Material �?__ ________________________________ <br /> Distance to nearest: Well - ---0.------------ Foundation _10__--------------- Property Line -;!-----_-------------- <br /> SEEPAGE PIT [u.]� Depth c f------ Diameter -- Number --------------------- Rock Filled Yes [�No I❑ <br /> Water Table Depth ---Ap-------------------------------------Rock Size"-' -------------------------- <br /> Distance to nearest: Well __�----------------------------Foundation ------ ------------- Prop. Line-­------------­----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit*# ____________________________________________ Date _____________.____________________) <br /> SepticTank (Specify Requiremerrts) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal <br /> ---------;-------------.---„_--------------------------- <br /> DisposalField (Specify Requirements) ---------- $------------------------------ ------------------------------ -----------------------------------------•--------------- <br /> ------------------------------------------------------------ <br /> -----------------`------ ------------------------------------------- -------------------------------------------------------------------------------------------- <br /> :� .4.(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 /> "1 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 ----- e,' r Title <br /> ---- ----------------------- 7. - s��/� <br /> - -- --- ---- --- --------------- <br /> (If other than o <br /> .42 OR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _. DATE ���^�.' 70 <br /> ------------------- <br /> BUILDINGi PERMIT ISSUED -- ------------ ---------------------- ----- ----------=--------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --- 1 --------�'��------��a�= <br /> G <br /> ` <br /> ------------------------------------------------------------ <br /> __________________________________________ _ ________;�� <br /> ---------------- <br /> ---------- ---------------------- <br /> ________________________________ _____________ ____________--__________________________.___________.____________ ____________._____ _._._ __Final Inspection by --- ------ ------- --------------------------------------------------------------------- ---------------------Date ...... -- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />