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j FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ ----------------------------- Permit No. __7 ;SS--. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> _ ___ <br /> -------- _-- ------------•-------------------- <br /> Application is hereby made to the San Joaqlh 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 /> r <br /> // -------•--- CENSUS TRACT -------------------------- <br /> JOB ADDRE55/LOCATION .__ &*"K-��-Cr- O�'t_C�-- -�------------ - <br /> li� ' <br /> Owner's Name ----------- 1! -------------------------------- -------------------Phone ------------------------------------ <br /> Address ---- ------------------ -------------- ----------\-- --- Litynseti# -------------- ------------------------------- <br /> Contractor's Name --------moi- i�-----------------------------------------------------=- r'k -- ----- Phone <br /> Installation-will-serve: ResidenceFE-Apartment-House. Commercial.,QT.raileroCovrt <br /> I <br /> Motel ❑ Other -------------------------------------------- <br /> NunTlYe of"living`F� iitS--4 Number-of-bedroom's _______ ge Grinder—:_- -____ Lot-Size _ _ _ _________. _ <br /> ��--•Garbo � -�--� <br /> Water Supply: Public System and name --------------------------------------------------------------------- [Private <br /> i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ �.0 K Loam.❑ <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type-- -------)-.._.I-__-_-- 1 <br /> (Plot plan, showing size of 11 t, location df system in .relation to wells, buildings, etc. mustAe placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} i <br /> PACKAGE TREATMENT [ ] SEPTIC TA K[j $ Size----------- ----------- =--- ow'r....... Liquid Depth-------------------------- <br /> ---- <br /> capacity -- -------------- Wpe ------------------- Mate ial- No. Compartments ----------------•---•- <br /> Dista ce to nearest: Wellr -----------------------------------0 oundation ---------------------- Prop. Line ---------------7...... <br /> LEACHING LINE [ I No. of Liries _______________ _ Length of each I*ine-.-----_----__________------ Total Length I---------- __-__________- <br /> f-L1 _..._ _s <br /> ' <br /> Type Depth Filter Material _ <br /> D' Box -- ----- T e Filt r `dterial ----- --------------- -• n <br /> Distance to nearest: Well --------- -------------- Fou dation --------__..__________ Property Line. ____f_-_._____......... <br /> . �.i <br /> SEEPAGE PIT [ ] Depth ---'�_------ t--- ------- .Rock Filled Yes No i❑ <br /> Diameter --_ Number ❑ [� <br /> Tl <br /> Water Table Depth ------------------------------------------------Ro k� ize`�`----r--� `�.�---- � � � <br /> �( I _ - Pro <br /> Distance to nearest: Well ___________________________________ ____FoundationI p. Line ----------------.---.- <br /> r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ----------------------------.------} <br /> 1 � .-1�- ---- <br /> Septic Tank (Specify Requirements) ______________ ___. .___:________ _ - -------------------•--••• <br /> I � � <br /> Disposal Field (Specify Requirements) _ Cs..+,rr ------- <br /> ---------- ---------------------------------- --------------- -------- <br /> Y <br /> I (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, isnd 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 i the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becQ object to orkman's o �pensation laws of California." <br /> Signed <br /> � ----------------- Owner <br /> BY --- ---- - -------------- --- -------- ------- ---------------------------------------------------- Title --------------------------------------------------- -------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> i APPLICATION ACCEPTED BY ------_ ----_. DATE __--Cp--2s ~�jf�------------- <br /> -------- -- ------------------------------------------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------ `----------------------- <br /> ADDITIONALCOMMENTS ------------r-----------------------------------------------------------------------------------------------------------------------;------------------------- <br /> r <br /> 1 <br /> ----------------------------------------------------'- -------------------- ----•--------------------- <br /> -� <br /> ---------------------------------------------------- --- -------- --=--- - - --------------------------- -=---r---- - <br /> Final Inspection b Date __l -2S-- -� ---- <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9..=-_. 1-'68 Rev. 5M. k <br />