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FOR OFFICE USE: I <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ <br /> Permit No: -w -_Z <br /> (Complete in Triplicate) <br /> 1 <br /> - ------------- ---------------------------- t � �� _ mss,..y. "V_ _..._�. _ _­ _-___Date Issued .-,? --- <br /> _._--._---------------------------- This Permif,Expfres I-Year From Date Issued <br /> - -------------- <br /> Application is hereby made to the San Joaquin Local`Healthbi'sfrict for a permit to construct and install the work heroin <br /> describedI This application is madegqin compliance with <br /> County Ordinance No. 549 and existing Rules and Regulations,_.. .. <br /> i JOB ADDRESS/LOCATION ------_---- - I- ---s - -4. ----------------------CENSUS TRACT ------------------------1 <br /> I Owner's Name h � 1� i--'-r7 <br /> } ----- ----- = 'Ph8`ne <br /> Address --------------/`' -3 ---- F- ------ -- ---------- - ------ .---- r ----------------------------------------••-•-- <br /> f 6 <br /> 1 1 i ,� p <br /> Contractor's Name ---------.- --�0w�----'----------------License # _ d Phone V66__%4)7_ <br /> r u . <br /> Installation will serve: Residence D_,Apartment House!-E] Commercial :❑Traile`r'Court i❑ <br /> Motel'❑Other ____.----- -- --- - ---------------- <br /> � 1 <br /> rfIIg lti <br /> usnber4af bedroornsv-_ ,____ <br /> G --- Lot Size _ <br /> WateSupplyPubicS stem arid name ----------------------------------- ------------------------------------------------ •------------Private <br /> [ �. <br /> Character of soil to a depth of 3 feet:k. Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ a <br /> Ifi `I lardpan❑ Adobe Fil! Material ------------ If yes, type _--_------------------------ <br /> 1-01,411, <br /> - -------- <br /> (Plot plan, showing, size of lot, location of'system-4n. relation to wells_buildings_etc, must be placed on reverse side.) � <br /> NEW INSTALLATION�-{No septic tank or seepage pit permitted if public sewer spva0oble within 200 feet,] - f� <br /> PACKAGE TREATMENT�{] SEPTIC TANK[ ] Size-.==--= -------------------.------------ Liquid`Depth ----------- ------s � <br /> Capacity -----------tom'Type -------------------- Material--*- -------- No. Compartments -----------_ C <br /> I 'T -"t' 153 1 1 '- <br /> Distance to nearesdWell __------___�_ _ _____Foundation -__---_---______.__ Prop. Line ----____________-_--•- <br /> [ ] -- ---- g h &f each line- --------1-------------- Total Length -.---------•- -- <br /> Lines ----_ ._ _ <br /> LEACHING LINE Do•Box __._-______ Ty'`e F1 e Material -----------------Depth' Filter Material ,-_---_-__--_--__._____________________.__-_ <br /> Distanceto nearest: I --------------r <br /> --t-- Foundation� -J �--------------.-,..Property, Line. ------------ ---•----- <br /> -- <br /> i r t Well '----- <br /> kSEEPAGE PIT [ ] Depth -_ ------_-4 Diameter � � - �_ Number -_�__�__�----________!__ Rock Filled Yes Z❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size---------- - " <br /> Tie II <br /> Distance to nearest- Weil --------------------------------------Foundation --------:----------- Prop. Line ---------_•----------- <br /> 1 ' -------- i <br /> REPAIR/ADDITION(P,rev._Sanitation Permit# _�______ __________�___.--_________ bate�� .___.______ i <br /> Septic Tank {Specify Requirements) y --------- l ------------------------------ ------------ <br /> / 1 ,� <br /> 0 <br /> Di poso eld (Specify Req u em ts) - ------ } --------------a--------------- <br /> e. <br /> 8:` = -- ------------- ------------------------ <br /> F �� /316 Y <br /> -------- <br /> --- ------- --------- - ------------------------I---- -------- /---------------------- ------------------ <br /> (Draw_existing..and-required addition on..reverse side) <br /> I hereby certify that I hdve prepareed this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Caws, and Rules and Regulations of the San Joaquin Local'ealthjDistrict. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the ork orf `which this permitAs-issued, i shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------- ---- ----------------------------------- Owner _- - <br /> By ---------- ------ Tithe. ----- -------------------------------------------------------------- <br /> (If othe n owner) <br /> ----- -t -r- FOR .DEPARTMENT-,USE-ONLY— •--�»--� <br /> ------------------------------- �. <br /> APPLICATION ACCEPTED BY -- ,,e•e-- --- --------- �I ------------------------------.. DATE --�-�-r------•------------------- <br /> BUILDING PERMIT ISSUED ------ ------------------------------------- ---------------------- - - - --------------DATE ---------------------------- ------------- <br /> ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------- ---------- ------V.__ <br /> ------------------------------------------- �; a <br /> -------------------------------------------------;- ----------------------------------------.--- -------------------------------------------------------------------------------------------- <br /> ---------- --------------------------- ---- - - -_-_-_- <br /> FinalInspection by. - -------------------------------------------------------- -----------------------------.Date ------ _ - - ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 E. H.'9 1-'68 Rev. 5M <br />