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FOR OFFICE USE: <br /> 4APPLICATION ' OR SANITATION PERMIT <br /> Permit No: V �� 5 <br /> -•-----------•-------- <br /> --------------------------------------------------- <br /> - -- ' ----""-� ----------- <br /> -------- � (Complete in Triplicate) <br /> ------- - -- <br /> Date Issued <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 /> ` r1 A iIVC4�� <br /> JOB ADDRESS/LOCATIONUi _..._ a -- �.. 1 - '/?e/.-CENSUS TRACT ------------------•------- <br /> �. ��.4 <br /> Owner's .Name -h.'a. " ------------------------------------------------- ----------- <br /> JOB <br /> Phone 'S . ...._�5 <br /> Address,--.-2"- 7 . G' /-- -. -..._.--. City 4_J1PA6 �4 ---- �y-------------_------------­- <br /> C, <br /> ----- -- <br /> Contracto'r's Name ......._ --_...License # -- / -- Phone 4.. r.3 . - <br /> -- - -" ---- �-� -- <br /> Installation will serve: Residence ® Apartment House-171 Commercial :1-Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------- ------- <br /> Number of living units------------- Number of bedrooms _3_-:...Garbage Grinder ------------ Lot Size .- - X-01e��("� <br /> Water Supply: Public System and name ----------------------- ---------------------•----.-....--------------- --•---------------- -Private <br /> Character of soil to a depth of 3 feet: a- Sand' Silt❑ Clay .0 Peat ElSandy Loam El Clay Loam C] .' <br /> Hardpan❑ Adobe'❑ Fill Material . -'- If yes,type <br /> (Plot plan, showing size of lot, location of system in relation to we'll s,'.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 /> Li p <br /> SEPTIC TANK f ] Size ----------------------------------•----------- quid De th <br /> PACKAGE TREATMENT. ..[ ] V <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 ,---------•----------------- <br /> 'D' Box --- --------- Type Filter Material ---------------------Depth Filter Material ------------------------------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. --------.--------------- <br /> ` <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 /> bREPAIR/ADDITION{Prey. Sanitati ' ,on:Perms## -------- --------•--------------------------- Date --------------------------- ------ t <br /> ` Septic Tank (Specify Requiremen �ts) /1� ' /-----1 -f--- ke1_,;1,cX----- <br /> r r <br /> Disposal Field (Specify Requirement ..";5;7_ 527/, T....---�'11r1V>'t.�5 % --- - ---- -C1---- <br /> /_�... <br /> / ---------------------------------------------- ------ <br /> >' i <br /> - 1 ----------- ------• <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 Jaquin Local Health District. Home owner or ticen- + <br /> sed agents signature certifies the Following: <br /> "I certify that in the performance,of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> r <br /> Signed -- : ----- - - --- Owner <br /> BYv-_ �-. ---------- Title ----------------------------------- <br /> (if <br /> --------------------------------- y <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY Y <br /> ------ --------------- DATE ------- �. --� ------------ <br /> APPLICATION ACCEPTED BY -------�s--R--©-------------------------------------"--------BUILDING PERMIT ISSUED ------ ----' -------DATE -------- ------------- ------------ <br /> ------ --------- <br /> ADDITIONALCOMMENTS - --------------- -----------------------------------------------------------.----------------- <br /> ------------ ------------------- -- - - --------------- -- ------ - --- -------------------------------------------------------------------------------- <br /> - -------------- ------- - <br /> - -------------- ---------------- =---- ----------------------------------------------------•--------- <br /> ----------------------------------- -- ----.------ --- ----- p ' <br /> - <br /> Final Inspec ' ---------------. ate ----- <br /> C <br /> --- I <br /> SAN JOAQUIN, LOCAL" HEALTH DISTRICT <br /> E. H. 9 1='68 Rev. 5M <br />