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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------- --------------- Permit No.74:3----------------------- <br /> (Complete in Triplicate) <br /> 1, . 7 Z <br /> This Permit Expires I Year From Date Issued Date Issue - ...-_- <br /> ------------------------------------------ s Jr , M1 <br /> Application is hereby made,to the San J aquin„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/LOCATION __ ---r=_- X---- '`'- - 1'2- CENSUS TRACT ­JL/I-------- <br /> - -------- ---------- <br /> Owner's Name --------- ----je1 --- ---------------- -----------------•---'-----------=- -------Phone -------------------------- --------- <br /> lew <br /> Address --------------- �� `( ' �------ ----•--. City --- - ---------------------------------------------- <br /> Contractor's Namek.•. -License # _ �. - -Y Phone <br /> Installation will serve: 'Residence ❑ Apartment House-[] Commercial : Trailer Court :❑ <br /> Motel ❑ Other ------ <br /> Number of living units:---/------ Number. of;bedrooms-----Garbage Grinder ------------ Lot Size ------------------------ <br /> Water Supply: Public System and name -------------------------------------- ----------------------------- -----------------------------------------Private <br /> f <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe ,Fl Fill Material ------------ If yes,type -------------_---__------- W <br /> (Plot plan,,showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) O ' <br /> t <br /> NEW INSTALLATION: ..(No septic tank or seepage pit permitted i ublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK Size-, --_ -_- --- ------------ Liquid Depth --- -------------- ----' <br /> Capacity�. Vis`b Type e-w,�---;ir-_ Material No. Compartments -------- <br /> Distance to nearest: Wel! ;, d_�-----------------Foundation -.-1-P-----_-_-_- Prop. Line -- -_-_�._.----__ ` <br /> i 11 <br /> LEACHING LINE of Lines ---------�-.--------I- Length of each line-------_�_a--s-- ----_- Total Length _-1-a-- --------------- <br /> ,. A <br /> 'D' Box -r-----.-- Type Filter Material - --P--------Depth Filter Material __-f-�l'---------------------------------- <br /> Distance to nearest: Well -------------- Foundation --------/ --------- Property Line. ------------------- <br /> SEEPAGE PIT [� Depth --.-z----_-_ Diameter -_ _- Number -_------�---_--.- -__ Rack Filled Yes ( No 0 <br /> Water Table Depth ------------YV-------------=-----------------Rock Size -- � <br /> I i <br /> Distance to nearest: Well -----_--�_---�----------------------Foundation ---�-- _�_------- Prop. Line ....-_-- <br /> REPAIR/ADDITION(Prev. Sanitation I Permit# ----------------------- ------ Date ----------------------------------1 l <br /> Septic Tank (Specify Requirements) ------------------- `--- ------------- -------------------------------;---------------------------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------`y-------------------------------------------------- ------------------------------- --------------- <br /> -------------------- - ---------- --------------------- ---- ---- <br /> (Draw existing and required addition on reverse side) <br /> 1 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.” <br /> Signed ---------->_--- -_- Owner i <br /> ------------------------------------- ------ <br /> ------------------------------ <br /> By ---:------------------------------------------------- -�- ----------------- Title --- '�------------- ------------------------- <br /> (If other than owner)i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t ------- ------ - ------------------------- DATE --- :7---7-�' ------ <br /> BUILDING PERMIT ISSUED ---------------ef------------------- ---------------------- ---------------------------DATE -- ---------------------------------- <br /> ADDITIONALCOMMENTS - -------47,1x<------------------------------------------- -------------------------------------------------=--------------- ----------- <br /> --------------------------------- ---------- --------------------------------- --------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ -- -- ---------------------------•------------------------------------------------------------------------------------ <br /> ------------------------------------ - - <br /> Date -------------------------------�r <br /> Final Inspection by: ----- `< ---- ----------------------------------- - ----------- <br /> 1 SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M f, <br />