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T t <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- o <br /> Permit N . <br /> ..__ - <br /> {Complete in Triplicate) <br /> --------------------- - ---- - <br /> Date issued _14-A6-`l " <br /> -___--------. -- ------------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to thean Joaquin Local Health Districtr.for a per to construct and install the work herein <br /> ---- --- <br /> . described. This.application-.is_made.-incompliance with County-.Ord inance_No. .549-and..existing Rules-and.Regulations: --- <br /> (V_ cam , "JJ J_ VSt-2s <br /> JOB ADDRESS/LOCATION 7T. X , -ka --- - -' CENSUS TRACT _-J-_y----------------- <br /> Owner's <br /> ___.__._____Owner's Name ---- -- <br /> - Phone ------------------------------------ <br /> - -------------------------- <br /> - CityAddress ------------ <br /> Contractor's Name ----------.License #/�M� ---- Phone <br /> Installation will serve: l Residence Apartment House❑ Commercial ❑Trailer Court '❑ <br /> Motel ❑Other - ------------------------------------------ <br /> Number of living units:------ ------ Number of bedrooms _______Garbage Grinder ----------.- Lot Size ------12_- --------- _______ <br /> Water Supply: Public System and name -------- ------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> HardpanF' Adobe ❑ Fill Material ------------ If yes, type __________________________ r <br /> V ' e� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> •� 1 <br /> NEW INSTALLATION:` „fit{N�do septic tank or seepage pit permitted if ublic sewer is available within 200 feet,) r �Z <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[�j Size__ �r1`__` ._�_X._ _________ Liquid Depth ----C-4_____________,_____ <br /> Capacity Type __ Material___ __ No. Compartments ______ ---- <br /> Distance to nearest. Well ------------------------------------Foundation -----1-0----------- Prop. Line __-------------------- I <br /> LEACHING LINE ['j No. of Lines ---------t------------- Length of each line----------- d.._f____ Total Length ------- .C'--..-__._------------ <br /> 'D' -- -----i . ----------------------- <br /> D' Box ___-s _____ Type Filter Material R_ _ Depth Filter Material �_ 1 <br /> Distance#o nearest: Well-_-----_✓r-__d__'- Foundation -------10--{_--______ Property Line __..__ .�___._.___ <br /> SEEPAGE PIT [ J� Depth __._ - __ _- 'b�ameter __-�-�_____ Number ___.__.____�-__--____. Rock Filled Yes [ No 0 <br /> Water Table Depth ______________ li <br /> --------- ------------=--=------- Rock Size -------------------------------- <br /> Distance to,nearest: Well ------------- ........ ___________Foundation ______ d.______ Prop. Line _-_-5--____._ - __- � <br /> REPAIR/ADDITION(Prev. Sanitation-Permit# --------7"_. _y `;------------ ------- Date ---------------------------------- <br /> Septic <br /> _________________ ______Septic Tank (Specify Requirements) <br /> ---------------------- -------------------- 5---------------------------------- ------------------------ ----------------------------- <br /> Disposal Field {Specify Requirements)- ------------ ----------------- ------------------------------------- -------------------------------------------•----------- -- <br /> --------- <br /> --------------------------------------------- <br /> - - 1 <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 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 to Workman's Compensation laws-of California." I <br /> - l <br /> Signed ------------------------------------------I-- ' a ---. Owner i <br /> BY ---------------- ----------------------------- ---DAI-9 , . . Title .. r <br /> (If other than.ownei) - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �� -------------------------- ---------------------------------- DATE I p_"/D -- Z----------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------•--------------••---------------------------------------------------------------- --------------------------- <br /> --------------------________-______.________k___--.------------------------------------------------------------------------___--__._____-________-______._____.____-______.________________.________.. <br /> -------------------------_---------------_--- <br /> ______ ________-________________________________.____________________________.______.______________-________________________.____._____________________.__._ <br /> FinalInspection by: ----------------------------------------Dat - ----------------------------- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />