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G <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No: -�p --r-- � <br /> I This Permit Expires 1 Year From Date Issued Date Issued <br /> d fp3--Zda,(f ' <br /> F 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/LOCATIONxt�.-- - - ------f- --- ----- --- - �CENSUS TRACT -----------------•---•---- <br /> Owner's Name <br /> / ------- , ---Phone <br /> X <br /> CAddress -- ------------ <br /> ------------------------------•------ <br /> c _ Phone`y = License # _� 7ContrN <br /> Installation will serve: Residence partment House❑ Commercial :E]Trailer Court !,❑ <br /> Motel ❑ Other -------------------------------------------- <br /> ' _ <br /> Number of living units:--./.-_._-- Number of bedrooms "______Garbage Grinder U---- Lot Size 3ya <br /> - -?__ __..________________... <br /> Water Supply: Public System and name ------------- ------------------------------------------------------------•-•----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Q Peat ❑ Sandy Loam Q Clay Loam;❑ <br /> Hardpan Q Adobe; Fill Material ------------ If yes, type ---------------------------- <br /> I Pi <br /> __-___------------------(P of 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 av ilable within 200 feet,) _ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size---W.___--_— - 4Liquid Depth A/-------------- -- <br /> Capacityj4__M__.___ Type ��' __ Material___ __ . ________ No. Compartments -_2'0.............. <br /> i Distance to nearest: Well _--- O_t-----------------------Foundation ------- Prop. Line <br /> LEACHING LINE No. of Lines ....�-__._-________ Length of each line-----_/ ------------- Total Length <br /> . <br /> - <br /> --- <br /> V Box _ P-f--------- <br /> a`Q................ <br /> + YPe Filter Material ��_----.-..De th Filterr Material � <br /> Distance;to nearest: Well . _f_______ Foundation _________ Property Line ---- -------- ------ <br /> SEEPAGE PIT �JV Depth _ ------- Diameter _33!------- Number ------2----_--.-.----------- <br /> Rock Filled Yes ] No 0 <br /> Water Table Depth --- "0--i----------- <br /> --------------------------Rock Size ----------------- <br /> s <br /> e <br /> Distance to nearest: Well _l_ j___ ---------------_--------Foundation I--.-.__----- Prop. Line __ _�_......__..__ <br /> 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit C# -------------------------------------------- Date --.-----------------_-------_-----) <br /> ( <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------.-----------------.----------------------------- <br /> Disposal Field (Specify Requirements) -------------------------------------------------------------------------------------------------------------.------------------------ <br /> I <br />- ----------------------------------------------------------------------------------- -------- ----------------------------------------------------- --------------------------- --- .-(Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 toWorkman's Compensation laws of California." <br />► \� <br /> Signed ------------------------- = Owner <br /> oe <br /> BY -- ------- -------------------------------------------- Title ----------- <br /> ----------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED i3Y ------------------------------ DATE-7~__J_?-X -•- ------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------ ----------------------------------------------------------------------------------- --------------------------------- --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- -- ----------- <br /> ----------------------------------------------- --------------------------------------------------------------------------------------------------------------------_-------- <br /> - ----------------------------------- - --- ;--- -------- --------------------------------------------------- ----------- <br /> Final Inspection by: ---------------------------------------------- -----------------------------Date7'�/--- 4.. -----•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />