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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> .................. A__................. Permit <br /> (Complete In Triplicate) <br />•••.................. ...................... This Permit Expires it 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 S <br /> described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: ' <br /> JOB ADDRESS/LOCATION ......46fivr_* 1 ...CENSUS TRACT ..................:....... <br /> Owner's Name .,$.�.► '�../ ._.j--yn .. ...., ._ .,e°,:: - phone ...... ...... <br /> Address �.r.........--•--------- .................................................. <br /> Contractor's Name .r; ,P.... -:' . ---_---------------.license #��`�S'�'.�{?. Phone <br /> Installation will serve: Residence 2f Apart�m,ent,House0 Commercial ❑Trailer Court 0 <br /> *Motel C]Other -..-. ------------ .......... <br /> Number of living units:............ 'Number of..bedrooms .........--.Garbage Grinder .-.--------- Lot Size .. ......___........_... ............... <br /> v <br /> Water Supply: Public System and name ..... ..-•--------------_--••--......------...... �_.......................------•..�..:..Private ❑ <br /> t t C`' <br /> Character of soil to a depth of 3 feet: � Sand❑� . Silt❑ Clay [D Peat E, 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, bulldings;eft, 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 ............. TYP® sfl+laterial...... ............. No. Compartments ..................... <br /> x <br /> Distance to nearest: Well ................................'...Foundation —_................. Prop. Line ...................... 6 <br /> W <br /> LEACHING LINE [ ] No. of Lines........................ Length of each linel.........................: Total Length ............................ V1 <br /> 'D' Box ...._... ---- Type Filter Material ^..... Depth Filter Material ............................................ <br /> R I Nr w r <br /> Distance to nearest. Well Foundation Property Line <br /> .....-...-.......... .•..---••-. <br /> SEEPAGE PIT [ j Depth ..................... -'"R k,.Filled Yes No i <br /> ........:....... ......_!Rock-------....-.._.._.. 0 ❑ � <br /> Water Table Depth Diameter-----••---•-•--:.....um..erg- Size <br /> Distance to nearest: Well .....__ ` ...:. w ,. + mss p .�-••: .._... <br /> Nr <br /> ---••--•--- ... ---I <br /> REPAIR/ADDITION(Prev. Sanitation Permit q6s _.:........._=�.�..-_•------------- Datendation ro me � <br /> �' r r <br /> Septic Tank (Specify Requirements) ..................... ................. ------ .................................... ............... <br /> k <br /> Disposal Field (Specify Requirements) .`. Q. !1�.. -ci----- --�.---• 1 -;1�• --G�=�1( .t� -�, <br /> .....................•-------- --•--..........----•------......•--- ..............:_.....................................................................--.•------------------................. -------- <br /> .lz.�G.. <br /> (Draw existing and required addition on reverse side) <br /> 1 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. dome owner or liven- <br /> sed agents signature certifies the following: <br /> "I certify that in 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 om n at of California <br /> Signed . � � ' <br /> 9 --- -- . OwneU� <br /> By Title <br /> .---- <br /> (If other than owner <br /> R-DEPARTMF,N U5E ONLY i <br /> . .. <br /> APPLICATION ACCEPTED BY ..!............ .:.. .. ..•-• ---- ... . ................................ DATE �L.. ..2.L/.. .......... <br /> BUILDINGPERMIT ISSUED ....... -- ------------ .-•--••-•••................................--....... .............. ... .................................. <br /> ADDITIONALCOMMENTS ....------•---...-•-•......................•---------------..................-----•----- •......................•..................:-.......................... <br /> ........................................................................................................................... <br /> --------------------------------------- - •••. •----�,.&AN.JOAQUI <br /> . --- -----------.................. <br /> - --•---••-- <br /> .... ..•••..........................Date ... .......11�-I';Z.�._. <br /> Final Inspection by: ...-. - -----__.--_ - <br /> LOCAL, HEALTH DISTRICT Q / <br /> z u 13 24 ,_;An D_ c" .7/72 <br />