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FOR OFFICE USE: <br /> AI ICAT2N FOR SANITATION PERMIT <br /> --- �', {Complete in Triplicate) PerNo. __7�. <br /> -------- ----- <br /> -------------------------------------- ------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued __&-_7_7 z^ <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 /> .4077 <br /> p --. <br /> JOB ADDRESS/LOCAATION �_ y9 _ 4_- ` __/ 'Av __ - _._ �Tle -CENSUS TRACT ..____________________ <br /> Owner's Name ----C-�,*4_3L,L---- ----------- --------------------------------------------------------- -------Phone .If3�_7_SS p <br /> Address ----4,3Q , y�G r� ------------------- ---------•--. city ------------ ------------------- <br /> 4 ? r� L-c�" ------- - �- a qq <br /> Contractor's Name -__�_r ,___.._ _______________- _____-.License #��`?.�___ Phone <br /> Installation will serve: Residence �partment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other-------------------------------------------- <br /> Number of living units:-----/--- Number of bedrooms ___'......Garbage Grinder ___________ Lot Size _________-________________________________ <br /> Water Supply: Public System and name -----------•---------- -------------------------------------------------•--------•-------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay g?`�eat❑ Sandy Loam ❑ Clay Loam <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 f ] Size-----------------------------------.------------ Liquid Depth ..________-___-___----- <br /> Capacity -- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ____________________________________Foundation ____________________ Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,--------___,__--------._--. (ti <br /> 'D' Box ____:_______ Type Filter Material ____________________Depth Filter Materia) --------------------I....................... �O <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number __________________________ Rock Filled Yes ❑ No i❑ I <br /> Water Table Depth ------------------------------------------------Rock Size -----------•-------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_..-_--___________--_______-_._._) <br /> �j <br /> Septic Tank (Specify Requirements) -------------- __ --_-------- _G __ /C._._ ifi� __„---------------------------- <br /> Disposal Field (Specify Requirements) --------fQ__�----.r� G1 ___./Z_ <br /> /ltd=--------------------------------------------------------- <br /> ------------------------------------------------------- ----------------------•----------------------------------------------- ----------------------------------------------------------------- <br /> ---------------------------------- - ---------------------- - -------- -- --------------------------------------------------------------------------------------- <br /> N (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 Workman's Compensation laws of California.” <br /> Signed Owner <br /> - -----.. �------------------- <br /> .By ------ - ------ --------- ----- - ------- ----- ------------- - - - --------- Title ----- - ------- -------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ------------------------------------------------ --------------------------------------------------- DATE ---------------------------------------- <br /> BUILDINGPERMIT ISSUED -------------- ------------------------ • "--_--------------------------------------------------------DATE __.---------------------------------------- <br /> ADDITIONAL COMMENTS = ------- --------- <br /> - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- -----------------------------•-------------------------------------------------/DISTRICT <br /> ----------------------------------------------------------------- ------- <br /> ------- -- ------ ------------------------------------------------------------------------------------ - - - - <br /> Final Inspection b ------------------------------------------------- ------- - ---•---Date ' f'------------ ---- <br /> SAN JOAQUIN LOCAL HE <br /> E. H. 9 1-'68 Rev. 5M � <br />