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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------- Permit No- lob lea <br /> (Complete in Triplicate) -------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From bate 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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._ 1�_'i1__ _ _rJ�= ----Pp'---------------------------------CENSUS TRACT ------------•------.._.._ <br /> Owner's Name ---I'MItg-ley----------(.-.......__S_�_/l'`--------------- -------------------- ------------=------Phone ----------------------- ............ <br /> Address -------���---------------------------- ---------------------------------------------•--- City --'---------------"------------------------ <br /> Contractor's Name ---------License # - 3---- Phone -------------------- --------- <br /> Installation will serve: Residence ®'Apartment House❑ Commercial ❑Trailer Court ❑ } <br /> Motel ❑Other -------------------------------------------- _ <br /> Number of living units-1------- Number of bedrooms __-------Garbage GrinderM ---_ Lot Size - _, JP __ __---.-------. <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------- ---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ffFill 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 /> 4' ,- -- <br /> Capacity 4?Q _____,__ Type --_ Material_ 'A_ ��c'. Na. Compartments ____�r_________________ <br /> Distance to nearest: Well _______________________Foundation .../6-------------- Prop. Line _____A------ <br /> LEACHING LINE [ ] No. of Lines _____f________________ Length of each line______ ______ Total Length _.-_-__________-- <br /> OG/< '' <br /> 'D' Box A/Q_______ Type Filter Materia! _1 ______________Depth Filter Material ____f ________.______________..._.._-- . <br /> Distance to nearest: Well ---A—P_f---________ Foundation -----ld------------- Property Line_ -............. <br /> SEEPAGE PIT [ ] Depth v7- ---______ Diameter __3-3 Number ____---_/_________________ Rock Filled Yes No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well __ IJ�__r------------------------Foundation --1__4 r ---- Prop. Line ----r�r_-_--___--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I <br /> SepticTank (Specify Requirements) -------------------- ----------------- --------------------------------------------,---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------ <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 ubject to Workman's ompensation laws of California." <br /> Signed r� - - <br /> ---------------------------- Owner <br /> ---------------------- <br /> 67- <br /> By ----------------------------------------------------------------------------------------------- Title <br /> (If other than owner) <br /> 4__,_�,�/Zi&)ADEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ---- - - --- -------------------------------------------------------------- DATE -------------------- <br /> BUILDING PERMIT ISSUED -------- ---- -- - --- ---------------------------------------DATE ------------------------------------------- <br /> ADDITIONA COM TS`---- -- ------- --r -------- --------------------_ __ ---------------- ------- <br /> ------- <br /> 6�-------- ; - - ------- ------- --- ------ 5'---------------------------------------------------------------------------------- -----------------------_------- <br /> ----------------------------------- --------------- - - - -- -- <br /> Final Inspection by- ----------------- ------------------------•---------------------------------------.Date r- /=`��-� <br /> O�U1N LOCAL HEALTH DISTRICT G <br /> E. H. 9 1-'68 Rev. 5M <br />