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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> /l-`- ----- Permit No. ._7...:............ <br /> 3 (Complete In Triplicate) <br /> ............ _ This Permit Expires t Year From Date Is=.bed Date Issued ... a. ------- <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/LOCATI - �'`. +, CG <br /> I <br /> ��. -'4 __. �. ' .... �... .: 't CENSUS TRACT • -- . <br /> Owner's Name --- ©-------- 1 ..... •.....rte ------•-• 1.... ............... ...... ......Phone.....:............................... 1 <br /> Address _�.. -1 -. `l/Lf ._u 5.,`�•',f" ::.`Gity .. �G� ��ti. <br /> �jj........................ <br /> Contrac#or's Nam .. �_�po�ment <br /> y ............. License # s ��.,, ,�. Phoe /�Installationwill serve:' Residence House flLCommetcial MTM11�Cot r . t <br /> Motel ❑Other ............................................ j <br /> Number of living un ts:--- Number of ro ms .. #" Garbage Gr ncier Lot Siz© f-'.�4-4 <br /> .. � ,� <br /> Wat r Supply: Public System and namej___ <br /> I . _ -- -- f1 . . �` ` 5.s..........2..-•--.....Private ❑ <br /> *+ �. u-4 <br /> Character of soil to a depth of 3 fee Sand oak\Silt Q,+ Clay 10 `"Peat 0 SandyfLoam 0 � go Loom C) <br /> . , <br /> Hardpan ❑ Adobe III Material ............ If yes,type ............... ............ <br /> (plot plan, show g sizelo llo locate o,of system In relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTAL!•ATION: k(No sept e;tank•.o seepage pit .permitted if public sewer is available within 200 feet,) —� <br /> PACKAGE TREATMENT [] SEPTIC TANKI ] Size.............. ..................... ........... Liquid Depth .......................... <br /> Capacity -------------- Type --------- .......... Material.---_---------••.... No. Compartments ....•............... y <br /> ( Distance to nearest: Well ....................................Foundation ......_ .............. Prop. Line ..................... <br /> LEACFIIN <br /> G LINE [ ] No. of Lines ---------------------- Length of each line............................ Total Length ............................ <br /> D' Box <br /> ............ Type Filter Material ....................Depth Filter Material <br /> Distance to nearest: Well ........................ Foundation Property Line ................ <br /> s,+ SEEPAGE PIT { ] Depth -------------_.... Diameter ---------__-.. Number ---------------------- Rock Filled Yes p No Q � <br /> Water Table Depth ------------------- ----------------------------hock Size .....-....................... <br /> ° Distance to nearest: Well --------------- ---------- .Foundation ---.....-_,_.. Prop. Line .............. <br /> a _-.-. ..... ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...-.........---------------------..-------- Date .--:-----•.......-........... <br /> ._-- ) r <br /> Septic Tank (Specify Requirements) t, V :"A_�.............. ...... <br /> _.Uis o al Field (Specify Req.uireme ts) , , ?� � •,� �-------- --...... ........... <br /> -_. e��� � � � -------------------- <br /> zz- i <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 Lows,,_and Rules and Regulations of the SanJoaquin Local Health:Dlstrict. Home owner or )leen- <br /> sed-agents sign ceture 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 i <br /> as to become subject to Workman's Compensation-laws-of-California:"--------- <br /> Signed ---- ----------- ---.-•------ -------------- OwnerZ- 4 <br /> By --------- ------ :_ ------ Title` ------ <br /> t er than owner) <br /> . FORD RTM USE ONLY <br /> Y <br /> APPLICATION ACCEPTED BY _.: !/l I i9ln D .,._..l.---- <br /> ------------ <br /> -' --75..-_ <br /> --------- - - <br /> BUILDING PERMIT ISSUED --..D TE ---------------•---....--------- ..........ADDITION CO ENT f <br /> �J --- <br /> Final Inspection by: _... -- -- ---•---- ... - -• - ©ate <br /> EH 13 2h 1-68 Rev. 5X N JOAQUIN LOCAL HEALTH DISTRICT 8/7.h 3M <br />