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FOR OFFICE USE: <br /> .............. APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicatel <br /> Permit No. <br /> ....................I........... -- 7/ <br /> _._____. This Permit Expires I Year From Date Issued 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, 649 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,..................................... rl r .... d�'is� ._...........__...._._CENSUS TRACT ....................... <br /> _.. <br /> Owner's Name .......................P0. ................................... ..Phone <br /> Address � _ -----•--------------•---•-•-----......._.... .... <br /> _.......�.��. �---------�-=---=�-�v`YG"'--•-•..--•--- City ---,1.�T�!!�`4 <br /> Contractors Name .......... 4.14.-r-eA � .._____-... License # .. C�`?.�?��. Phone <br /> Installation will serve: Residence Apartment House C] Commercial ❑Trailer Court 0 <br /> Motel ❑Other ----- ................-•.................... <br /> Number of living units:..-./..___ Number of bedrooms ..a2.......Garbage Grinder ---------- _ Lot Size .......7...............................: <br /> Water Supply: Public System and name ---------•.................:.........----•---------------------------------------•-••-•---------•-••-•--•------Private [� <br /> Character of soil to a depth of 3 feet: Sand]] Silt❑ Clay ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................ Liquid Depth ........... .............. <br /> Capacity .................... Type ---------_- ...... Material----_-_---._.-.--- No. Compartments <br /> r <br /> ' Distance to nearest: Well ....................................Foundation ...................... Prop. Line <br /> LEACHING LINE [ ] No. of Lines -------------------_--- Length of each line-------•-------------.------ Total Length ................._....._.---so <br /> 'D' Box ....._...... Type Filter Material :...::..............Depth Filter Material ......... <br /> Distance to nearest: Well . Foundation TO <br /> .....---•-•----._.._. ......................-• Property Line ........------••--....- <br /> SEEPAGE PIT [ ) Depth Diameter ................ dumber ....,__..................... Rock Filled Yes ❑ No C3 . <br /> Water Table Depth .......................................Rock Size <br /> Distance to nearest: Well Foundation ... Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ........................................... Date __._._........................--..) <br /> Septic Tank (Specify Requirements) A - ;: • __ <br /> Disposal Field (Specify Requirements) _....__.__ Sl?_____._. --=�-G! ---f�_--�?-- --------------- <br /> F -�: 4 k <br /> _.......................... _ _ __.___-_______._-___-____________-----__-..._....__..______._._�---.._--_----•________...____..___._______._...__._......__.......... <br /> ' (Draw existing...and required addition'on reverse side) <br /> I hereby certify that I have prepared this-application and th-cit'the work will be clone in accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local HealtWDistrict. Home owner or licen- <br /> sed agents signature certifies the following: -_ _ -- ." '' <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 /> as to become subj7cttWrkma ompensation laws of California." <br /> ���� <br /> OwnerSigned ....... ..�-•`- - -�=`•--•---•--I-•-----•--•--------------•----...------------•- <br /> r <br /> By •.......................................•-........-•-•--•------•--.........•-•--•-- •--....... Title ....... ............ ......................................... <br /> (If other than owner) <br /> FOA DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-___.__ ..... DATE ._�..^s.�_:�`?�............. <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------- <br /> ---- <br /> .--------•---------------•-----.----.-..DATE ........................................ <br /> ADDITIONAL COMMI=NTS ................................................. <br /> NTS ......................... <br /> ... ........................ • . <br /> ......................................I..--•-•---- ------•--------a--;-------------------.------.------._._._-_.._.__....._._....._...--- ..----............_..............._._ <br /> A <br /> ------------------------------------------••-- ......_----- .. .............................................. ---- <br /> 47 <br /> Final inspection by: ................. . ......-..__.... <br /> -•-- ••----------------•--•----•-•........... ...------------•--•-----•--...-•-•---.Date ---• -••---------�. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C 1 <br /> 3 <br /> E._H.13 241-'68_Rev. 5M_ -- - -- — 7/723., <br />