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t <br /> FOR OFFICE USE: I <br /> APPLICATION FOR SANITATION PERMIT <br /> // -3z Permit No:'�_Z_--6.3 <br /> (Complete in Triplicate) <br /> ------ <br /> --------------------------------------- 1 --7 Z <br /> Date Issued <br /> ------------- This Permit Expires 1 Year From Date Issued <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 /> - - -.. :CENSUS TRACT <br /> JOB ADDRESS%L`OCATI'ON -- ------------ `1 <br /> Owner's Name l' -- t r ----------------------- ------ ---- --Phone`Z= �_ 7 -•---- <br /> AddressI ----=------------- City ------- - --- 7-N-f-------------------- -_ ---•------ <br /> Contractor's Name --- -- - --------------------------------------------License # _ O? �ll , Phone9 <br /> Installati ,will serve: Residence XApartment House-E] Commercial :❑Trailer Court ,❑ <br /> Motel ❑ Other -------------------------------------------- <br /> ` , t <br /> Number of living units:--------F-.- Number of bedrooms ___'Z-"_Garbage Grinder __. ___ _`_ Lot Size _--_.,t '`J -�-------•-------- <br /> Water Supply: Public System and name._:--:--.-:_-------. -:--------.- - -_-- ---- --------------------- ---------Private ❑ <br /> i <br /> Character of soil to a depth of 3 feet: ! Sand'❑ Sift❑ Clay ❑ Peat ❑ Sandyloam ❑ Clay Loam <br /> t <br /> Hardpan ❑ Adobe 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 /> j <br /> Capacity -------------------- Type _j------------------ Material---------------------------------------- No. Compartments ------------------..._ <br /> Distance to nearest: Well -A---------------------------------Foundation ---------------------- Prop. Line .-------------__...-_ <br /> LEACHING LINE [ ] No. of Lines _k__ -------------- Length of each line- ..------------------------- Total Length ----:-_----.------- ........ <br /> 'D' Box ----------}•T.ype Filter Material ____________________Depth Filter Material _.______-____---____-_________.._______._. <br /> Distance to nearest:-Wel-l-1---------------------- Foundation ------------- --Property Line -------------• <br /> SEEPAGE PIT [ ] Depth ---------____'___f-Diameter _______________ Numbe; _-_- ------ Rock Filled Yes E] No [J <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 Requiremenfis) ----- -- - ------------------ <br /> U - - <br /> Disposal Field (Specify Requirements) --------- <br /> ------------------------------- <br /> ________ <br /> --- __- <br /> ------------------------------------------------------ ----------------------- ----------= ---- ------- <br /> t <br /> t (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the-work-will L 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 Workm n's Compensation laws of California." <br /> ' Signed---= '--=---- ---------- - - - ------------------------ Owner <br /> BY - ------- -- --- --- ----------- - - - -------------------- Title ' <br /> - --- -------------------- <br /> 1 <br /> o er th ner] <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, Ay ------- ----- - ---- -- - - --- - ---------------------------------------------------------, DATE ------ <br /> BUILDING <br /> ----BUILDING PERMIT ISSUED-�., ------------- ----------- ----------------------DATE -------------- ---------------- <br /> ._.�.,_ADDITIONAL COMMENTS ------- -- - -- - - / -----R------------------ ---------------- <br /> --------------------------------------- <br /> --------------- <br /> ------------------------------ ------ - --- ! ---- --------------------- --- <br /> z -------------- <br /> ---- - -- -- - <br /> - - --- -- --- ------ - - <br /> d <br /> - f <br /> Final Ins6 ction -- -- -- ---------------- <br /> - - ------------------------------------------------------------------------------------------------ <br /> Final Inspection by: /r --------------------------Date ------------- �'� , <br /> y SAN OAQUIN LOCAL HEALTH DISTRICT <br /> a � E. H. 9�' -.7-'68 Rev. 5M <br />