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-FOR OFFICE USE: -� - <br /> APPLICATION FOR" SANITATION PERMIT �� <br /> ------ Permit No: <br /> (Complete in Triplicate) <br /> -------- ----------------------------- <br /> - Date Issued 's <br /> -_---_------_---------------------- This Permit Expires 1 Year From Date Issued <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 coliance with County Ordinance No. 549 and existing Rules and ReguI tions: <br /> JOB AbDRESS/LOCATION __--- '.- _ � �41�3/�dt---------------uLS�4..:---r}" ---.-------------------CENSUS TRACT -------- <br /> Owner's Name ---- ��---------------------------- Phone ------ . <br /> Address ------ ------���Wrt 16- � <br /> _ �$ ------ ----------------- . City -� I---------------------- ---------•- <br /> Contractor's Name ____ _� / _ '1----- - -��----lA s--------.License _5 5- __ Phone <br /> Installation will serve: Residence , apartment House ❑ Commercial ❑Trailer Court. ,❑ <br /> r <br /> E Motel ❑ Other -------------------------------------------- �f <br /> Number of living units:.--. Number of bedrooms _. Garbage Grinder j_ Lot Size _._ _S 0dO CJ -f- <br /> ------ / 1 --------------- <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 0 <br /> Hardpan Q Adobe ❑ Fill Material_ : a` If yes,hype`-`"_----------------------- <br /> (Blot-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 f ] Size-----------------------------------•------------ Liquid Depth ---------------._.---.- - - <br /> CapacitY -------------- - TYPe ------ Material---- `----------- No. Com rtments -------- = . <br /> Distance to nearest: We -----------------------------------Foundation ----------- --------- Prop. Line -------.------........ <br /> l'� <br /> --- Total Length -----� •--•---------- <br /> Ines L th of each line._-_ - .- 4 r <br /> ' De 'Iter Material ------J9-----------------------------•- <br /> LEACHING LINE �o.Box�'_��.___-- Type Filter Material _ ____ <_--___ <br /> t Distance'to nearest: Well ---- 1 ------------- a �Q--------------- Property Line --- ----------------- <br /> SEEPAGE PIT Depth ---9---------- --- Diameter -- --- ------ Number -.------' ----- _---_ -- Rock Filled Yes No <br /> Water Table Depth ------------------------------------------------Rock Size ----- --- ----------------- <br /> Distance <br /> --------------Distance to nearest: Well _.--------------------------------------Foundation ------------c_---._ Prop. Line ---.--___.-.-..------. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ----------------------------------.-1 <br /> Septic Tank (Specify Requirements) ------------------- -------------- R ----^------ ---------------- <br /> �0 ' 1%51y --- 5- Sl�.�°tn <br /> Disposal Field (Specify Requirements) _ Q �/�- -- <br /> �}a}2- . ' ----- --- � 1`EPA <br /> 1 -- ► -C- 1 n� 5-----=--------==- -----'-------------------------------------------- - - -- --- --------.- ---- <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 Joaquin Local Health District. Home owner or licen. + <br /> sed agents signature certifies the following: Ie <br /> "I certify that in-the performance sof the work for which this permit is issued, I shall not employ any person in such manner l <br /> M as to bec?mf subject to Workm s Co ensatin Iaws 'California." y f <br /> ;' <br /> Signed ..... -- - ---- --------- -- ----- --------------- ----- ----= ------ Owner <br /> BY ------- - - ----- ------- - -- - - --- --- ------------------------ Title ---, ----- <br /> :_ - :� ---- ------------ <br /> ------------------------------- <br /> f <br /> --------- _- "f other than ownerJ_ <br /> I FOR DEPARTMENT USE LY <br /> -------------- <br /> APPLICATION ACCEPTED BY ----— .1_`Q------------------------------------------------------------------------.--- DATE ----- >5-F <br /> f <br /> BUILDINGPERMIT ISSUED --------------- -----------------M--------------DATE------------------- ----------------- <br /> ADDITIONAL COMMENTS - - ----�� :---L ( ----- LLt= lL� <br /> --------------------- --- ----------- - ---- --- --------------- ---- - ------------------------------------------------------- -- <br /> a - ---------------------------------- ------ - ------------ -- --- -----. ----------------------- --------- <br /> ----------------------------------- ---- - ----------------- ` " : ----- - --------------- <br /> I, Final Inspec ' - --------------------------------------------- ----------Date ---�--'--- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />