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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------- - ------------------------------------ f712Q�3 <br /> -------------- <br /> Permit No. 4 <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date issued l/-6 <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ------- < ---- &e.,L <br /> se --:-o4�le-- -- - �"� -------CENSUS TRACT ------- <br /> D'`�^.- --_-_-------- <br /> Owner's Name --- --------------- -------� --------- -------------------- --------------- ------Phone7 '. 0 <br /> Address J,,o ----City <br /> Contractor's Name S-Qw..�---------------License # ./d_0.57t_----- Phone VK776D_7----- <br /> Installation will serve: Residence ❑Apartment House❑ Commpercial:❑Trailer Court ;❑ <br /> Motel Other ------ _ - -----_.___ <br /> Number of living units:-----!____ Number of bedrooms ---•______Garbage Grinder ___________ Lot Size bCR,1 0 _-°__________ .. <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam Clay Loam <br /> Hardpan ❑ 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: fNo septic tank or seepage pit permitted if public sewer available within 200 feet,) // \ <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ S- e-----------5 __ - __------------------ Liquid Depth _-- ------.--.----- Q <br /> Capacity/>00 _ Type _ ____ Material_44 .__• . No. Compartments __. `___---------- <br /> 1.r 0 1 / <br /> y Distance to nearest: Well ------------ -------------------Foundation ------------ Prop. Line ------------- <br /> LEACHING LINE [-] No. of Lines -------3------------- Length of each line--------(v_t?_........... Total Length ........... <br /> D Box .s_✓ Type Filter Material __ ___ _ _____Depth Filter Material __/tP .....................__..____._ <br /> Distance to nearest: Well __,-_ - Q Foundation ------�Q------------ Property Line ---/0 <br /> SEE PAG_ E'PIT- Depth <___.f__7<_____ Diameter -------_____ ------------- Rock Filled Yes 10 <br /> -_-- Number --------------- ❑ No <br /> Water Table Depth -------------------------------------- --------Rock Size -------------------------------- <br /> 1 <br /> 'I'Distance,to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation,Permit# -------_------------------------------------ Date --_______________________________) <br /> SepticTank,(Specify Requirements) ---------------------------------------------------------------------------------------------------- ----------.•---------------------------- <br /> Disposal Field L(Specify Requirements) ------------------------------ -------- -------- ---- --------------- ••------------- <br /> _ "_______ <br /> ___________ __ _ lam-f--`�____ ______-ryYIC-� ____ <br /> ------------------- -------------------------------------- -------------------- ------k------------- ------.--------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will bVlone 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:_.,I 1-_,..- -.. — -- -- . <br /> "IlceVtify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as tc become subject to Workman's Compensation laws of California.i <br /> Signed ------------------------- ----------- Owner <br /> By ---------------- - Title ----- <br /> (!f other t owner) <br /> FOR DEPARTMENT USE k ONLY <br /> APPLICATION ACCEPTED BY ...7i-R-- --------------------------J---- --------------- ------------------------. DATE `�� ----------- <br /> BUILDINGPERMIT ISSUED --------- --------------------------------------------------------------- -------------- --------------DATE ---------------------- -------------------- <br /> A--D---D--I-T--I--O------N----A------L <br /> -------------------- -------------------- <br /> ADDITIONAL COMMENTS - ------------------------------------- <br /> --------------- <br /> ---------------------------- ------ -------- ----------- ------------------------------------ <br /> ---- --------------- --------------------------- <br /> ------ ------------------- - -- ------- ---- -- ---- -------------- ------------------------------------------------------------------------------------ ------ <br /> ------------------------ -------- - <br /> Final Inspection __._ ��--__ ______.Date <br /> r------------------------------------ <br /> SAN JOAQUIN trOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />