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FOR; <br /> rFFICE f15E: APPLICATION FOR SANITATION PERMIT <br /> g' Permit No. . S~ 3 <br /> ,...,..... - (Complete in Triplicates <br /> :....._.._.................:.. Date Issued ..../..:.� S........... <br /> -7J <br /> Th <br /> 1 Year From Date Issued <br /> ...................: .................... *pent Expires <br /> Application is hereby made to4he-Son-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 /> V ...: <br /> r <br /> JOB ADDRESSAOCATIO :..... .............. CE fL <br /> Phone .��?Z3 T r <br /> ....... .............. ......---• CENSUS ......-- <br /> Owner's Name � �J - '-"'" "'•' <br /> Address �_....1`":T.�..................... City _.. <br /> ... <br /> ..................... _ . . <br /> Contractor's Name d.. ---........_''license # Phone . <br /> t <br /> Installation will serve: Residence Apartment House 0 Commercii�al OTrailer Court fl +. <br /> Motel ❑Other.......-...-•----•----••----•--•----••:-:=- <br /> �. <br /> Number, of living units-_..h_.___ Number bedrooms --.2......Garbage Grinder ... L5*Size ..... .............. <br /> Woter..Su' l ublic System and name ------�: :e--- ---.-------.. ............... ............._..... -k ......�......Private ❑ <br /> �.PP.Ye _ Y , i . <br /> Chars er oflsoil to a depth of 3 feet: ""Sand b Silt 0 Clay Q Pea-t-0`""Sandy loam fl Clay Loam❑w <br /> Hardpan [] Adobe Fikl?lVi te�iair. . . ... _ If yes,type............... ....I....... <br /> i� <br /> (Plot plan, showing size of lot, location of system in relation toLwell`s., buildings, etc. must be placed on reverse side.) , <br /> NSW INSTALLATION <br /> .-'V--(No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I Size........... -.: . .............•••••... Liquid. Depth ....................... <br /> Capacity -------------•------ Type •-••-----•----...... Material.........._........-- No. Compartments ......................%P E <br /> Distance to nearest: Well Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of lines _. length of each line----------.-L.............. Total Length <br /> ...Depth Filter Material •• • <br /> Filter Material --•-•-•---= - -.. ....................................... <br /> Distance to nearest: Well ............ ...:....... foundation Property Line .......................aP- <br /> SEEPAGE PIT [ ( Depth -------------------- Diameter .-•-----=_.:..:. Number ......... ___....- ........ Rock filled : Yes ❑ No ID <br /> Water Table Depth •................Rock Size .-•---••------._..,.----........ <br /> r <br /> Distance to nearest: Well Foundafion Prop. Lino......................... <br /> REPAIR/ADDITION(Prev. Sanitation Penni## ............... Date ----- ....••••.._.. ) <br /> i ....T <br /> i t yt J <br /> Septic Tank (Specify Re uirements) ...................•-- -- ._... <br /> ••• ............. <br /> C .r tI Disposal Field (Speify Requirements] •-.-_-__-- �� f - -------- ------ -- ------------------------------------------------ <br /> c <br /> t• <br /> u <br /> - �_ ----- ..-- .............•-_. ---...... ........... <br /> . .. <br /> l (Draw existing and required addition on reverse side( <br /> 1 hereby certify that 1 have prepared this application and that the work will go 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 /> k sed agents signature certifies the following: <br /> '"1 terrify 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 /> f <br /> Signed -----------•-•-------- :..------ _ - Owner <br /> BY •. . .....---•- <br /> ...-_ Title ________________ -------__._......__..__.._-..__:._._.--__..__._-.._.- <br /> (I of r than owner) <br /> FOR DEPARTMENT USE ONLY <br /> — _r-•---. .­ . 1 i� --» .-W .-•DATE /� ...:..: <br /> APPLICATION ACCEPTED BY _ ° _. = l <br /> DATE .__ ...._._..--- <br /> BUILDING PERMIT ISSUED ------------- ------------- ------ ------------- <br /> ADDITIONAL <br /> COMMENTS :.---._.... ----------a ......... ...--- -......... . ........................_..----••---- <br /> --------- ------------- _ <br /> --. ------------- -- <br /> Final Inspection by: -•--------------------=---- �AN­­JOAQUIN <br /> .._�,�... l DateEH 13 24 1--68 Rev. 5M LOCAL HEALTH DISTRICT 8/7h 3M <br />