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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ,.t <br /> Permit No: <br /> (Complete in Triplicate} <br /> ------------ -- -- ---------------------- -------- - ;,! Date Issued <br /> 11� 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 /> � yy� <br /> JOB ADDRESS/LOCATION .--Of ..?-62-A -----------------------CENSUS TRACT -------------------------- ' <br /> .a <br /> Owner's Name -- '� --------------- Phone <br /> AddressCity 1/ " <br /> - 1 <br /> Contractor's.Name FTic��- , .,s'------------------------=-----License #,�7V�.� _ Phone �2 <br /> i <br /> -Installation will serve. Residence XApartment House❑ Commercial IZiEmiler-CourtT;❑ r <br /> Mote! F-1 Other ----------------------------------------- <br /> Number of living units:----- Number of bedrooms -__Garbage Grinder > __ Lot Size .--- ----------_- <br /> t <br /> Water Supply: Public System and name --------------- -- - Private <br /> • ------------------ - - --- ---- --_�--------------�- --„-------------- <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay :❑ Peau❑ Sandy#Loam ❑ ,Clay-Loam <br /> Hardpan ❑ Adobe [] Fill Material ------------ If yes type ;-----x ---I------'' <br /> (Plot plan, showing size of lot, I'ocation-of system in-relation-to-wells, buildings;etc --mustbe zplaced on reverse side.) t <br /> NEW INSTALLATION:--�,(No septic flank or seepage pit permitted if,p blit fewer is available within 200 feet) f <br /> PACKAGE TREATMENT['] �-SEPTIC TANK P �. .. Size-- ____ Liquid Depth_-------------- Q- <br /> �: { ` - <br /> •., / ,fid ✓Material__ a_ No. Compartments -_ <br /> Capacity TYpe ' p - --s;•--=---- <br /> --Foundation f <br /> Distance t6-nearest: Well _ ------ Prop, Line e-`----- <br /> LEACHING LINE ENO. of Lines --- -------------------- Length of each line-. _- -r/__-------- Total Length - .`------_-_ <br /> ter Material- _ I'D' Box �� Type Filter Material����{�oe�pth ` � -------------- " <br /> Distance to nearest: Wel! _��� p ty �---------------•=•--- <br /> SEEPAGE PIT ` [a]. ' Depth /_0- Diametero2XY Number _ --A_-�-------- -------- Rock Filled Yes ' No C] A <br /> t401Water Table Depth ----------"--- --------------- Rock Size, / <br /> (Distance to nearesf:-Well- =�`-,�9_ ,;;� -------...-Foundation ` --_-:- Prop. Line --�--------------- <br /> REPAIR/ADDITION{Prey. Sanitation' Permit# ----------------------- --------------- Date _--_----_--_---.______________-__-] <br /> �s. 1 f 1,r <br /> SepticTank,(Specify Requirements) ------------------------------------------------------------------------------------------------------------ ----------------------------- <br /> Disposal Field (Specify':Requirements) ------------------------------------------------------------------------------------------------------------------------------------- t <br /> --- ------- --------------- ----------=-------------------- ------------------- a <br /> 9 f e=q j <br /> Draw existin and re wired addition <br /> -------------------------------------------------------- <br /> ---------------------- <br /> dition on reverse side) <br /> t <br /> I hereby Icertify 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 iri;the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to'Workman's Compensation laws of California." <br /> Signed 1------ - ---t`r _----'-'Owner <br /> BY ------ # ---------- '*--------------- Title ---- ------------------------ - .. <br /> ----- ' =- <br /> (If other,: owner) <br /> 4 FOR DEP.ARTM NT USE NLY <br /> + f ------ DATE .- U <br /> APPLICATION ACCEPTED BY ---------= ---- - -------------- ----- - -------------`--- - - - - -- ---------- - - ----------- <br /> BUILDING PERMIT ISSUED ------------'--'---------------------------- ---- ---------------- ---- -- ----- - ---------------- DATE --------------- --------------------------- <br /> ADDITIONALCOMMENTS ----------------------------- ------------------------------------------------------------.--- ---------------------------------- <br /> -------------------------------------------------------=---------- -------- <br /> ,� <br /> -- -------------- --------------------------------- ---------------- - - t ------------ ------------ - _� ^�. __ <br /> - - -= <br /> Final Inspection b f ! ;!---------- Date __..-LU- <br /> p Y= ------------------------•--------------------- <br /> 1 SAN JOAQUIN LOCAL HEAL DISTRICT <br /> C or <br /> E. H. 9 1-'68 Rev. 5M <br />