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-�: l <br /> __�-FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- -----'- ---------------------------------- - ----- <br /> - � - <br /> ---- --1._a_a-tel 7----- ^ <br /> `73 I',7 f * (Complete in Tmit No. <br /> riplicate) I Pert # <br /> --.--- ------ This Permit Expires 1 Year From Date Issued Date Issued _17/_1--- <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> I described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> r <br /> z JOB ADDRESS/LOCATION!_J,2_7------- -____/T-��I�/ ,�C- ----------- -------------------- -CENSUS. TRACT -------------------------- <br /> Owner's Name 6; -Q ------------------------- <br /> Phone <br /> } Address �/ r ---------------------=------------------------------------------------- City �-------------------------------------- <br /> Contractor's Name __.��r1_ ------------------------_---License # _/27 _- Phone <br /> i <br /> Installation will serve: Residence,�"partment House❑ Commercial :[7]Trailer:Court ;❑ <br /> r <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--/----.-- Number of bedrooms -zP-------Garbage Grinder ---IV&---- Lot Size _fL7UJ�----� ._............... <br /> Water Supply: Public System and name ---------------------------------------- --- ---------------------------•------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: SandE] Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> Hardpan ❑ AdobeA 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 /> x r 4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ii <br />' PACKAGE TREATMENT ' SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -----------------•---_---- <br /> r 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 /> k <br /> ;D!` Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------- _-.-:_... <br /> h Distance to.nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------- ...... <br /> SEEPAGE PIT [ ] Depth -------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size =------------------------------- <br /> Di II once to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------.__... ------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _--_------------------------------) <br /> SepticTank (Specify Requirements) ---------------------- ---------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify 'Requirements) _//Q a s 1 " -_/,T -------------------- <br /> 11 <br /> '! (Draw existing and required addition on reverse side} <br /> t <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 shalt not employ any person in such manner <br /> �as to become su ' ct to Workm n's Compensation laws of California." <br /> Signed ------------ ----------- --- Owner <br />'. BY -------- - --- --i--- -- <br /> - -- - ---- <br /> - - ----------------------------------------------------------- Title -----'-- -------- ---------------------------------------------------- <br /> (if than Towner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY CV ----------------------------------------------------------------- --- DATE -----7,//--7/-7,---------------- <br /> BUILDINGPERMIT ISSUED '-------------- -------------------------------------------------------------------------- ----- --------DATE --- -------- ----------------------------- <br /> ADDITIONAL COMMENTS - <br /> --------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- <br /> ia <br /> ---------------------------------------------------------------------- ------------------ <br /> --------------------------------------- --'------ ---- <br /> Final Inspection by: - �i /-:------------ ------- ---- --------------------------- ------------Date <br /> SAN JOA UIN LOCAL—HEALTH DISTRICT <br /> E. H. 9 1 68 Rev. 5M. # <br />