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NO-HpLa l °c z <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------- (Complete in Triplicate) <br /> Permit No. .. . . o <br /> ---------=---------- ------------------------------------ <br /> Date Issued ---M-1�2=y_? <br /> _________________________________________________________ This Permit Expires 1 Year From 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 made in compliance with County Ordinance /No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-,10/,V____d__t���j`_VIff--___R%vez-__-- --L__U_�— CENSUS TRACT __________________________ <br /> Owner's Name ------/-�Y-//�9_*--A--------T/-�!/t� Q-`Yj,P.-�q-�--------------------------- -------------------Phone ----------------------- ............ <br /> Address __.31�_)--OUp-----`'A-5�a&---.l d --�O T_ / - -E?--•--. City -- zwjr;G,y---------------------------------------- ............... <br /> Contractor's Name bN '>F O�-------- ----------------License # ---------- ------ Phone ------------------------------ <br /> Installation will serve: <br /> Re <br /> Installation J Apartment House❑ Commercial ❑Trailer Court M <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----I----- Number of bedrooms ____ _.---Garbage Grinder ------------ Lot SizeSa_X__l�d?!___._._ <br /> - <br /> Water Supply: Public System and name ------ _ X`---R _*---------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;( <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- VIN <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 [ ] Size-___%4 % _ S__ _Q_1---------- Liquid Depth <br /> Capacity 1.4.0-P------ Type RY6'_CAF7Material___- No. Compartments _ ................ <br /> Distance to nearest: Well ___________________________________Foundation ----la__'___...__ Prop. Line ...4�.............. <br /> LEACHING LINE [ ] No. of Lines ___________________ Length of each line---------------------------- Total Length ___________________________ <br /> 'D' Box ------------ Type Filter Material Depth Filter Material --------­-------------------- <br /> Distance <br /> ______________ ______________Distance to nearest: Well ------------------------ Foundation A_S7---------------- Property Line ------ ............ <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------- ---------------------------------------------_---------- <br /> Disposal Field (Specify Requirements) ____-_-_____ ----------------------- <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 sub'ect to Workman's Compensation laws of California." <br /> Signed i / 71)-& - ------�-,- -Al------------------------------ Owner <br /> By ------ -- -- -------------- --------------------------- Title ----------------------------------------------------------------------- <br /> (If other than <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------- ------------------------------------------------- DATE ------------------------------------------ <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -------- ---------------------------------- <br /> ADDITIONALCOMMENTS ------------- ----------------------------------- --------------------------------------------------------------- ------ --------=--------------------------- <br /> ----------------------- ------------------------------------------------------ ------------------------------------------------------------------------------ --------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------- -------------------------------------------�TRICT <br /> L <br /> /� ------ <br /> Final Inspection by: --------------------------------------------------------------------------------------------- C%✓� 1-----Date ------Ir�'�------------------------- <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DI <br /> E. H. 9 1-'68 Rev. 5M <br />