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FOR OFFICE USE: <br /> APPLICATI0I4 FO SANITATION' PERMIT '�7 <br /> (Complete in Triplicate) Permit No, -.-7-------_--- <br /> --_------------------_--_.--.--.-------------_-----.- This Permit Expires T Year From Date Issued <br /> Date Issued ---f-!C:;-- <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 /> G� <br /> JOB ADDRESS/LOCATION .- �_-- 1-_�- p ------�----- --------rte�4- I`� <br /> CENSUS TRACT <br /> 16 <br /> - L <br /> Owner's Name ----- --------- .-__ {1 - s �----------------------------------------- <br /> -------Phone <br /> Address ------------- C ---------------------------------------• Cit <br /> `- <br /> Contractor's Name ...... _ _______________ _ _ __License # - �-----------y <br /> ❑ P---- ❑ ❑ --- - Phone ------------------------------ <br /> Installation will serve: Residence\ A artment House Com rcial Trailer Court <br /> l <br /> Motel ❑ Other ---77'-)L-�--�---_--- -- r <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------_--------_---_-_-_-.--------_-_----_. <br /> Water Supply: Public System and name ----------------------•----------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay O� 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,) D <br /> PACKAGE TREATMENT [ SEPTIC TANK{ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material--------------------- No. Compartments ------------ ---•----- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------- .__-------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------.-.--_._._------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Fitter Material -------------------- ----------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---_-_-.--. ----.--_.--_ <br /> SEEPAGE PIT [ Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit+ --------.----------------------------------- Date ----------------------------------11 <br /> SepticTank (Specify Requirements) -------------------------------------- -----------------------I--------------------------------------------- � ------•------------ <br /> Disposal Field (Specify Requirements) __�- - /lam <br /> - - ---- - ------ <br /> - ------------------------------------- <br /> ----------------------- -------- --- ---------------------- VIP ' <br /> ----------- --------- --------- x 1 <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 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: <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 subject to Workmc�Compensation I* <br /> s California." <br /> Signed ------------------------------------------- C Owner <br /> BYE- <br /> itle - - ------ '----------- ------ ----------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY M, --------------------------------------------------------- DATE --- ---y-7'-7�------------ <br /> BUILDING PERMIT ISSUED-- --------------------------------------------------------------------------------------- <br /> --------------DATE -----------•----------------- <br /> ADDITIONAL COMMENTS --- --------- --------------- ------------------------------------ <br /> ----------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------- -------- - -------------- --- ------ <br /> Final Inspection by:. r. ..� ------------------------------------------ -------------------Date ----------------------- <br /> AN JOAQUIN LOCAL HEALTH DISTRICT �A, <br /> E. H. 9 1-'68 Rev. 5M <br />