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'FOR OFFICE USE:' <br /> •�N"w APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> ..............•.............. <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued .3�. .. <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 /> r��� <br /> JOB ADDRESS/LOCATION �'(''o,... e 4�l�It` � ` - w_ 3 CENSUS TRACT <br /> Owner's Name ....±..-._ a�s�( ----•---•-•-_-------........................... Phone ``6 :-S�?o ......._.' <br /> .-. <br /> Address ------------------••-- •- ...-..• City ....57± o-N............. ..--..._ ::_...4.................. <br /> Contractor's Name .-.--..--- ...............License # �a.�` 34 3..-_ Phone <br /> Installation will serve: 1; partment House❑ Commercial '❑Trailer Court 0 <br /> Motel '[)-Other ....::. ........ ........................ <br /> Number of living units:----._ --- Number of bedrooms !-__Garbage Grinder_­,­Lot Size_.'- - ________________ <br /> � t <br /> Water Supply: Public System and name ........ ............ '...........•.....•-- •. ................................ Private [ <br /> Character of soil to a de th of 3 feet: Sand 11, t N E <br /> I? t- �❑ Silt❑ Cla ❑ Peat❑ Sandy,Looms 17 Clay Loam ❑l <br /> _ _ w,. ­ ` 1 <br /> Hardpan ❑ Adobe Fijia eriai �...._.----- If yes,type-._..---}---- ------•_•-... k <br /> (Plot plan, showing size of lot, location of -system. in relat13n't9.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 240 feet,) <br /> ti <br /> PACKAGE TREATMENT ( ] SEPTIC TANK.t j Size................................................ Liquid Depth ...........-.-............ <br /> . <br /> Capacity ----•- -•----------• Type .................... Material--------------------_- No. Compartments <br /> a <br /> Distance to nearest: Well ------------------------------------Foundation ...................... Prop. Line ....................... <br /> LEACHING LINE [ j 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 /> ...:­ <br /> SEEPAGE PIT [ 1 Depth ------------- ---- Diameter ________________ Number ----------- .......... Rock.Filled Yes [] - No,Q 14 <br /> Water TobI.e Depth ..............Rock Size ....... ' <br /> Distance to nearest: Well ..................•.....................Foundation ..................-.' Prap. ,Line .._-_-..___._____ <br /> 4ji; <br /> ITION(P ev. Sanitation Permit#............................................. Date .................................. <br /> p�cpy Requirements) 1 oSt ._.... .-• ............................. ...............�.... ............ .......... <br /> Disposal Field (Specify Requirements ___________ __ <br /> ­-------------------------- .33 " •/�_��' 1RY•V m �t Y�71 7 ..... <br /> ---..--.---.".!..'.`.. -5._- .. .................... .......--.....---..._._.._--..._-_ <br /> ------------ <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 this permit is issued, I shall not employ any person in such manner ` <br /> as to become subject to W man's Compensation laws of California." ;. <br /> Signed .......• -- _ -- -------- - -------------------- --- ........... ------._-- ------------- Owner <br /> By ................ . .. -. -- . . Title . .. -....................................... <br /> I <br /> i � <br /> (If other than owner) <br /> OR REfAT USE ONLY ' <br /> APPLICATION ACCEPTED BY . ..... _ .... t '.. DATE <br /> BUILDING PERMIT ISSUED ---------- - --- =--- -- - -------- ----------------=- -------- -------- ---------------DATE .....................................:..... <br /> ADDlTlONAL COMMENTS ....-... . ,. �-.__-..._ <br /> ::::::::::::::::::::::.-:::::::::::::::::::::::... :: �t: :::: .........................................:. :::: :::::::::::::::::::::::::::::::::::::: <br /> -- .. <br /> ••-.Date .-.....��... . .............. <br /> - Final inspection by: -..:.....•---•------• - ....__--•---------------------------------------------------------------- ----- <br /> N JOAQUIN LOCAL HEALTH. DISTRICT CP ; <br /> E. H.1-3 241-'68 Rev. 5M 71723 M <br />