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.FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT / <br /> ------------------ -- ------------- - - _�-- -- -! <br /> (Complete in Triplicate) Permit No. <br /> Dc#te Issued <br /> --------------------------------------------------------- This Permit Expires ] Year From bate Issued ��i�f�----- - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and in"stall the work herein <br /> described. This application ismadein compliance with County Ordinance No. 549 and existing Rules"and Regulations: <br /> JOB ADDRESS/LOCATION �? ,f�_ ------- - --------------------------1f,�__-_-__---___----------------__CENSUS TRACT ____ ' <br /> ---------------------- <br /> Owner's Name ---- it k -------- - .., ------------------------- <br /> ------- ------------ -=---------------------Phone/'0 ------ <br /> Address ------- + C' "/��f'� r� ------------------------------- City --------------------------------------------- <br /> Contractor's Name ------7,-'_XAW11-----------------------------------------------------License � ---- Phone __:"r1 � <br /> Installation will serve: Residence ( artment House❑ Commercial❑Trailer Court l❑ <br /> i0 Motel ❑Other -------------------------------------------- <br /> Number of living units-----/�----- Number of bedrooms _n�------Garbage Grinder --.-.__-- Lot Size/--?�V_-lt-- -{--........... <br /> Water Supply: Public System and name --------------------------------------------- ---------------------------------------------------------------Private <br /> Character of soil to a depth pf 3 feet: Sand'[4`*"Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam,E] <br /> a <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 se gr is available within 200 feet,) <br /> J$ ,4s 11 <br /> PACKAGE TREATMENT [ ] .',S.EPTIC TANK [� �Size �___���+_.�.�`�.__.-- Liquid Depth ________________ <br /> t <br /> Capacity` _��_.__ Typ _ _ Materiaa '��1` No. Compartments ----------------- <br /> Distance to nearest: Well _�!�__________________________Foundation 1p_-op <br /> Prop. Line ___ �_�________ <br /> LEACHING LINE [.]-.D` Box Length of each line-- ,t�---------------- Total Length�lQ_,.___._._._______ <br /> '5 .Box of n�s Type--Filter Materiawroo '______Depth Filter Material -is_______________�______________ <br /> " Distance to nearest: Well --------------- Foundation 4-� __________ Property Line _��__..______________ <br /> SEEPAGE PIT [`] Depth ---_- .:-;_______ Diameter ___________-___ Number ____________________________ Rock Filled Yes ❑ No i❑ <br /> i e Water Table Depth ------------------------------------------------Rock Size --------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------- <br /> I REPAIR/ADDIT16N.(Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 <br /> SepticTank (Specify Requirements) -------------------- -------------------------------------s-----�-------- -------------------------- -------------------------------------- <br /> Dis osal Field (Specify Requirements] -____ ------------ <br /> - ---- -- --- - - - ---- -------- ------ ------ <br /> a [Draw existing and required addition on reverse side} .r <br /> I hereby certify that I have prepareTd°this application and that the-work will be done'lw 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 <br /> ---------------- --------------------------------- -- - <br /> By --------------- ` - " ---------------- -----------•------------------------ Title LL�W.Z, X, �r-------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- ---------------------------------------------------- DATE --------- ----------- <br /> BUILDING PERMIT ISSUED ----------------------------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- <br /> ------------------------------------------- - <br /> r <br /> --- <br /> �� � -------- <br /> Final Inspection by: --------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />