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FOR OFFICE USE: <br /> / APPL TION.FOR SANITATION PERMIT <br /> �--------------- .. Permit No-.6-9:7-&,52, <br /> (Complete in Triplicate) <br /> ------------------------------------------------- ------- This Permit Expires 1 Year From Date Issued Date Issued __/-4--- <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 iinfcompliance with County Ordinance No. 549 and existing Rules and Regula�ftions. <br /> JOB ADDRESS/LOCATION � .�_`(_--.-----/��._�--- G' ---- -- --------.CENSUS TRACT -- --_[.._------------ <br /> Owner's Flame �'r1 Q -P1 1 ,� FYI e ��------------- ----y--------------Phone I ------ ---- <br /> Address �� ------------- y, CFXCA---t--------------------------------------.-.------ <br /> Contractor's Name ----- --- -- - --- ------------------------------------ ----------------- --------------License # ----- ------------------ Phone ----------------------- <br /> Installation will serve: Residence }Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other ---------------------- ------------------ <br /> Number of living units:---j------_ Number of bedrooms-------Garbage Grinder 4/0 Lot Size -__-----_- <br /> Water Supply: Public System and name ------ f---------- - � -------------------------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe K 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------------------------_ Liquid Depth --------_-------.-._,----- <br /> 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 /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------- <br /> 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 /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------.-------_. -- ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------- ----------- -----------------•-­- <br /> Disposal Fiel (Specify Requirements) _ __Y'_ . ----- . --____ .yQ <br /> ---- ------------------------------------------ -------------------------------------------------------- ------ <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 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#his permit is issued, I shall not employ any person Ir such manner <br /> as to becom s ( -t to Workman's omp nsation haws of California." <br /> Signed �C% - <br /> -- - ----- -- ------- - - - ----- ------------------------------ Owner <br /> By ---- -- --------------------------------------------------------- ---------------------- Title ---------- -- ---- <br /> (If other than owner) <br /> FOR DEiiMTMENT USE O LY <br /> f <br /> APPLICATION ACCEPTED BY ----- - -------------------------- _DATE ------ - -{ --- ---/---Q' <br /> ------ <br /> BUILDING PERMIT ISSUED ---------------------------- ------- -- <br /> -- ----- ---------------------------DATE ------------------------------------------- <br /> -------------- ----- - <br /> ADDITIONAL COMMENTS --------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -- -------------------------------------------------------------------------------------------------------- --------4--------------------- <br /> Final Inspection by: .- ; Date ....t om V <br /> --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1. <br /> E. H. 9 1-'68 Rev. 5M. <br />