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FORDO-FFICE USE: <br /> .. <br /> PPLICATION FOR SANITATION PERMIT <br /> = Permit No. <br /> (Complete in Triplicate) <br /> " I Date Issued 5-7_1—Z7=6 <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 . +------ c--C1ce-------2-J---- ---------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name ______ --_.___--_.Phone . _ <br /> Address ------ ---- �lxf'� =� -------------- -------------------------------------------- City --------- -----------------' ------------------------------------ <br /> Contractor's Name ---- ni ----' -- -�'�-----------'-----------License # / s 1-- ------- Phone <br /> r <br /> Installation will serve: Residence VQ Apartment House°E] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other-------------------------------------------- <br /> Number of living,units:________ Number of bedrooms _______Garbage Grinder ------ Lot Size ---- V-__e-d-�r_!?M---------------- <br /> d <br /> Water Supply: Public System and name ______________________ ___ s---" Private <br /> «� <br /> --------- V <br /> Character of soil to a depth of 3 feet Sand'❑ Silt❑ Clay ❑ Peat E] Sandy Loam -® Clay Loam E];I t.- . . - - . . - __" t I <br /> Hardpan ® Adobe ❑ Fill Material ------------- If.yes, type ---------------------- ---- <br /> (Plot plan, showing size sof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic ta;nk.or seepageP•t Permitted ifP <br /> public sewer is available within 200 feet, <br /> PACKAGE TREATMENT SEPTICTANK;[ Size________________ __ __ _ # '______ <br /> ' <br /> Liquid Depth ------------------------ <br /> Capacity -!#------------ Type -------------------- Material--------- No. Compartments ---- w <br /> Distance to{nearest: Well __________________________________Foundation ___ '_ ___________ Prop'Line ---------------....... <br /> 17. 4 . <br /> LEACHING LINE [ ] No. of Linels` ---------I------------- Length of each line__-___,. _1 ` Totai`l-ength -�_0_ -___-__--___---__ t�1 <br /> 'D' Box ---` ---- Type Filter Material QQCK—--------Depth Filter`Material ----- - ---- '-- ----------------------- <br /> Distance to nearest:. Well __,_ ------------ Foundation ---, 10---- __ Property Line-_________________ i <br /> SEEPAGE PIT [ ] .� Depth -F------- Diameter 3_3 ----- Number -------- <br /> ----------- Rock Filled Yes No i❑ <br /> Water TabldDepth _ _-..._--Rock Size <br /> TTT <br /> : rT Distance to nearest: Well ________________________________________Foundation -------__-- -_.-__ Prop. Line --------....... , <br /> REPAIR/ADDITION(Pre'v. Sanitation Permit# _.4_)1-] w-vi------------- Date __________._______________________) 4 �, <br /> SepticTank (Specify.Requiremenis)'---------------------------------------------------- ----------------------------.--------------- ,.:--------------------------- <br /> Disposal Field (Specify Requirements] 1 '1 1 ® d = Y' �' ---------14-------- --------------- <br /> 'a!' �.5---------- --- ?'- ---.----------` - ' <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 ac ordance with San Joaquin <br /> County Ordinances, State Laws, arid Rules and Regulations of the San Joaquin Local Heglth District. Home owner or licen- <br /> sed agents signature certifies the following: n., <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 /> d T <br /> as to becomesubject to 0rkman's Compens tion laws of California." I <br /> Signed fig- = - ""=" - Owner <br /> BY ----- --- G'�L�!:. ---- ---- --- ------------------ <br /> /�u T_ • k <br /> III---YYY__-""" <br /> ....� <br /> ------ ------ -- ---------- - �- � -� =--'------- Title •- '----- -- ----------- - a <br /> (If other than owner)' <br /> + a <br /> '1 EOR DEPARTMENT USE ONLY <br /> 71 <br /> APPLICATION ACCEPTED BY --- ------------------------------- -------------------------------- DATE,5 i99� <br /> - --------------------- <br /> BUILDING PERMIT ISSUED ------- --{ ---------------------------------------------------------------------- -------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ----------f 'r-----------------------------= ---------_--------------------- <br /> x �a <br /> ---------------------------------- ------------- 1------------------------------------------------------------------------- --------------------------------------------- <br /> <------- ----------------------------------------------------------------------------------- <br /> Final Inspection by: --------------------------------------------------------------------- - Date '� --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />