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r <br /> FOR OFFICE USE: <br /> { 3% APPLICATION FOR SANITATION PERMIT <br /> -----{ [ Permit No. <br /> " - ---r- <br /> #. (Complete in Triplicate) <br /> ;__ _ ,- a This Permit Expires 1 Year From Date Issued Date Issued/ <br /> ____---__ <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/LOCA N <br /> 2D-6---------�}--------- 7 ---CENSUS TRACT -------------- ----------- <br /> � <br /> Owner's Name �' -------- --------------.Phone --------------- <br /> ------ <br /> Address - ----� �.��=----------------------•- City -------------------------------------------------------------- <br /> r �t <br /> Contractor's NamIlke_-l- - - $:--- - License <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--------- Number of.bedrooms _ -z—....Garbage Grinder.'--- Lot Size --------------------- <br /> Private <br /> Water Supply.. Public System and ----- = - E] <br /> t Character of soil to a depth of 3 feet nd'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> 6 <br /> Hardpan�D Adobe Fill Material ------------ If yes, type ---------------------------- <br /> 3 (Plot plan, showing size of lot, location %6fsystem in relation to.wells, buildings, etc. must be placed on reverse side.) <br /> i <br /> NEW INSTALLATION: (No septic tank or seepagepit permitted if public sewer is available-within 200 feet,) S <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] . Size-y= ------ -------------------= --"Liquid Depth ----_--------------_-.----- <br /> Capacity Type __ Material No. Compartments ----------------- <br /> Distance to nearest: Well '�- _____________Foundation ____._---_----__---_ Prop. Line ---_-_-_-- _:__....__ <br /> ,r <br /> LEACHING LINE { j No. of Lines ------------------------ Length of each line---------------------------- Total Length ,_____-_`'_:,__........__ <br /> D' Box '-_--- Type Filter Material �_� ------------Depth Filter Material --------------------•----------------.------ <br /> Distance)to nearest: Well _----_--__-r______}._= Foundation --------------- -------- Property Line ___-------------------- <br /> j SEEPAGE PIT [ ] Depth -------------- -- Diameter _ __________ __ Number ___________-____.______-___ Rock Filled Yes E] No ❑ <br /> WaterTable Depth --------- ----------- --------------------------Rock Size -------------------------------- <br /> Di sta nce'to:nearest. <br /> ------------------------------- <br /> Distance'to:nearest: Well ---------__1--------- ---------------Foundation .------------------- Prop. Line --------------- ------ <br /> AEPAIR/ADDITION(Prev. Sanitation Permit F# ........------------------------------------ Date ----------------------------------) <br /> I ) <br /> Septic Tank (Specify Requirements) -- --------------- ---------------------------- ------------------- ---------,---------------------------- <br /> Disposal <br /> ----------------•---- ---- <br /> Disposal Field {Sp�---i�y Requirements) ----- --- - - ------- ------ ---- ----- — --------- -----•----------- <br /> -- ` `�Jry ----------------------------------------------------------------------------------------- ---------------------------- ----- <br /> --- <br /> --- <br /> j ------------------------------------------------ --- ._..�._ <br /> I � �(braw 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 ofj 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 /> l <br /> By I GAJ �...� / <br /> --------- ---------- ---------------- Title .. <br /> ---- - ------------------------ <br /> (If other th ner) +yr I t e <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---74W----------- DATE _ 7,_•• ; �G <br /> BUILDING PERMIT ISSUED -------- - - l --------- -------DATE ------------- --------------------- ------- <br /> ADDITIONALCOMMENTS ------ - # ----------------------- ------------------------------------------- -------------=--------------------------- <br /> - <br /> ---------------------------------------------------------------------I---------------3 ./y <br /> - ----------------------- - <br /> . <br /> ______________________-_--_ -___-------- -----_---._.--_-_-_--_-__-_--_-------_--_-_--_________-----___---------_----___•________-______-_._-___-_---__-_---------_-____-_---__--__-_________-_..--_._ <br /> , ` ----------------------------------------------------- <br /> _T <br /> t <br /> -------- <br /> - <br /> -DateFinal Inspection by. J---- <br /> SAN OAQUIN <br /> l�G <br /> LOCAL HEALTH DISTRICT <br /> i E. H. 9 1-'68 Rev. 5M <br /> i. �� <br />