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- � 4 <br /> FOR OFFICE USE; ;_- r <br /> va '^ APPLICATION FOR SANITATION PERMIT <br /> ?�------------�O' <br /> -------------- - - <br /> (Complete in Triplicate) Permit No. <br /> ----------------------------------------- --------------- <br /> This Permit Expires 1 Year From Date Issued 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 madeincompliance with Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI ------ 4�I--------E---------- - ----- ----------------------------------------CENSUS TRACT <br /> -•---•---- <br /> Owner's Name ,- ------ ------------------------------ -- Phone - ?�--- <br /> 01- <br /> r <br /> Address -------------- - .5 --- -----'---- Ci - -------------------------------•------ <br /> { -------- -----.License #fD 1/- Phonewa6'96Q ---- <br /> Contractor's Name _____________ __ __ ___ __ <br /> Installation will serve: —Res idence-X.Aparftent-House,E-Co m.-m.e.rciai ❑Trailer Court ❑ <br /> ❑Other •� ° �----------------------------------- <br /> Motel -- <br /> Number of living units.-/------- Number of bedrooms `r -_=-Garbage nd r ______.____ tot Size`' V V <br /> -- --- ----------- <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`❑ ytiy <br /> Hardpan ❑ Adobe Fill Material ___:____._ if yes,type ___________________________ r <br /> k <br /> i <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 TRE=ATMENT [ ] SEPTIC TANK'[ ] ] Size------------------------------------------- ---- Liquid .Depth -------------------s------ <br /> Capacity -.--- ---- ;T.YPe ---------------- Material---------------------- No. Compartments ------•------•--� <br /> Distance to nearest: Well ______s ________Foundation ______________________ Prop. Line -__-_-__-_-_---�.... \ <br /> --------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length _________-___-__---_----__ <br /> 'D' Box .__ ...... Type Filter Material ____________________Depth Filter Material <br /> Distance to-nedrest: Well ------' --------.- Foundation ________________________ Property Line -------------------------- <br /> SEEPAGE; PIT [ ] Depth '___________________ Diameter' ---------------. Number ---- ----------------------- Rock Filled Yes '[] No (] <br /> Water Table Depth ------------------------------------------------Rock Size ------'------------------------- <br /> Distance to nearest: Well _________ _____________________________Foundation _.=.... <br /> ------------ Prop. Line ---------------------- <br /> REEPAIR/ADD#T)ON(Prev. Sanitation#Permit# -------------------------------------------- Date ------ ------------------ <br /> I _____°_------.---------_) <br /> Septic Tank (Specify Requirements) ---------------------- <br /> ___________ <br /> i <br /> Disposal Field (Specify Requirements) -___-____ `' ' - <br /> - _ = <br /> --- - ------- ------------ ------------------------ <br /> _- - - ---------------------------------------------- <br /> k <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: r E <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. Com'pensation.laws,of Califor'nid <br /> Signed --------------------------------------------#---------------- `l`-- ------------------ Owner <br /> BY --------- ----------------------------------------------- --y -------------- Title --- ------- -- <br /> ------------------------------------------------------- <br /> (If other than owner) I V <br /> FOR PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- --------------------------------- DATE ------V7�� - ----------------- <br /> BUILDING PERMIT ISSUED ----------- ----- ----------------- -----------------------------------DATE ------------------------------------------- <br /> ADDITIO L M T� - --- --- ---- <br /> ------------/----------------------------------- ---------- -- - <br /> ------------------------------------------- -- --- - - -- - -- ----------------------------------------------------------------- -------------------------------------------------------- ------ <br /> Final Inspection b - -- •------ - ---- --- - -- -- --- -------Date ---- =��= 6r- <br /> P Y - - - - <br /> __ OAQUIN LOCAL HEALTH DISTRICT <br /> 1. H. 9 1-'68 Re . 5M <br />