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t <br /> ` -OR OFFICE USE: <br /> . i <br /> ► APPLICATION FOR SANITATION PERMIT <br /> -----------�-�-Q�-----•--------------- <br /> (Complete in Triplicate) Permit No: --------------------- <br /> ---------=----------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 . QDO®--------}�I.9 S--fes--o 1V---------�1--G--------- --------------------.-CENSUS TRACT .......................... <br /> Owner's Name _ Phone -S�.S /6.9 ----- <br /> Address = <br /> -----•-------------------------------------------- --- city `�_ <br /> Contractor's Name ---F., 14 n�374!',V- y Y- 541 :_:____.___:_:_.-.License# ��6,-�'�-�`�-- Phone _-'�__�j.3.—Y ZOO_ <br /> f- -- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other --------------- -------------------------------- <br /> Number of living units:_ Number of bedrooms.--.--------Garbage Grinder ------------ Lot Size -------------------------------------------- Q� <br /> Water Supply: Public System and name .- « --------------------------------------Private ❑ O <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;® <br /> Hardpan E]' 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.[ ] Size_-=_ --------- --------------------------------- Liquid Depth --_.--.-_-••----------.-. <br /> Capacity - -------------- Type ---- ----- Material--- ---- ----- No. Corr�}�ar#n�e►its_ <br /> Distance to nearest: Well ---------------------------------------Foundtition ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] 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 /> SEEPAGE PIT [ ] Depth ---------------------- Diameter ------------ Number ._________ ----------------- Rock Filled Yes '❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -----=------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date •.------•- ••---•------_.___----) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------•-----•-----------~---------------------------,,.--------------------------- <br /> Disposal Field (Specify Requirements) -------- -ad--- 1�______ _ •'r%otYA ---- 1,C-AC,- /7 �' !NP--------------- <br /> - <br /> ---------- °�' fix'-f '�'N�' /'-T- T`Aw-)"� ' �' Wong n�s Res T 1 ao!.`5....... <br /> i�Ta_ se -------------------------------------------------------------- ----------------------------------------------------- <br /> (Draw existing'and required addition on reverse side) <br /> 1 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, 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 ---A7!A it._rhOIy <br /> Y ----- --- O-N------... ----•------------- Owner <br /> BY --------- 7 I ------------ Title ---------------------------------------------------(If FOR DEP TMENT—USE ONLY <br /> APPLICATION ACCEPTED BY ---- ---------------- -- ------ ------------------------ DATE------ ------- <br /> BUILDINGPERMIT ISSUED --------- ------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------ ----------------------------------------------------------------------------------------------------------------------=----------------------- <br /> ----------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- ---------------- <br /> ----- <br /> ------------------------------------------ ------ --------------- -- --------- --- ------------- <br /> ---- <br /> ------------ - ------------------------------------------------------------- <br /> Final Inspection by cSi1.`� Date = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />