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I <br /> F R OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> lD / ----- Permit No. <br /> ` ) (Complete in Triplicate) <br /> :.---- --------------------------------------- t <br /> Date Issued <br /> I This Permit Expires 1 Year From Date issued <br /> Application is hereby made to the San Joaquin Local Health District for ❑ 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 /> CENSUS TRACT -----------------=---•---- <br /> JOB ADDRESS/LOCATION .------��_,��---�:-- - ---�-°-'._�•-�C'_i_ ���-- -�''�. �-- --------------- <br /> � ` � �� '� ------------------Phone --- 413 <br /> Owner's Name ` �--���--- --� -_______-_` <br /> Address - -------- ---- 0. ' ----------------------------------------------------------- .Y -----v5---:fit1_c�_./ -T`�= ----------------------------- <br /> --. Cit '�-------- <br /> Contractar's Name __ 1--_ Phone -614 -2Ca -- <br /> /�9s _ _-!.!etifQ;S - -C----- a4►'� �`- License # __`'6 �} <br /> r " <br /> Installation will serve: Residence 0 Apartment House <br /> ❑ Commercial :❑Trailer Court. <br /> iMotel ❑Other --------------------------------------------- <br /> C'-eler_' -----•-- <br /> Number of living units:-____!------- Number of bedrooms __.____Garbage Grinder -_E�-C� eLot Size __.ca7____-__---- - <br /> Xt • <br /> Water Supply: Public System and name _ = Private <br /> _ �t <br /> Character of`soil to a depth of 3 feet; Sand'o Silt 0 Clay ❑ 'P-eat,❑�, "Sandy Loam ❑ Clay Loam ❑ <br /> fir•; 'Hardpan ❑ AdobeFill Material ------------ If yes,type ------------------------- -- <br /> i <br /> {Plot plan;"howing size of lot, location of systemin 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,] 4 �j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[k �� Size---d� .-1- -- ------ Liquid Depth - --------•------- <br /> Capacity ---- Type ---,424a-;------ Material_ _ ('fir No: Compartments __ ______ PropLine <br /> _ ----_----- <br /> Distance to nearest: Well"____, ---Foundation ___ . Line __'_ -------r .� <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of...each-line-----------------------j--Notal Length -----`---_----------------- <br /> D' Box __________ Type Filter Material *s <br /> _ gx <br /> ' al ____________________Depth Filter Material <br /> m. <br /> Pro er Line <br /> Distance to�nearest: Well-----------""'--_-'- "`""'Foundation -----------------'-;---_ <br /> P tY •----------------------• <br /> ' ,:_-_`------- Rock Filled Yes [3 No 0----------------- <br /> SEEPAGE PIT- [ Depth --- Diameter ---------------- Number - --_- <br /> Water Table Depth ------------------------------------------------Rock Sized k- <br /> Distance toinearest: Well ----------------------------------- Prop.Prop. Line ------------- ...... <br /> •'' <br /> Date __.__`---�--•------------------1 i <br /> ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation TPermit# ---------------_-----------------------------. ' <br /> Septic Tank (Specify Requiremen s) ---- ----------------------------------------------------------- -------------------------- ------------------------------------- ---- <br /> - ,� 'Cay-J------ -�� --------------- 5� r��Iaf, , <br /> Disposal Field (specify Requirements) ____. - - ----------- -------- - - -- --- <br /> - <br /> 1 ------------------------------------------------------------------------------------ <br /> .�R _ _ ________________________________ R <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 subject to Workman's Compensation laws of California." <br /> Signed <br /> I Owner <br /> Title ---- <br /> - <br /> (If other than-bwner) <br /> - <br /> FOR-DEPARTMENT USE.,ONLY <br /> APPLICATION ACCEPTED BY ------------------s !--------------------------------------------' ---------------------------. DATE _---/D--- ----- --------- <br /> BUILDINGPERMIT- ISSUED _-_-_----- ' --------------------------------------------- ----------=--------------DATE --•---------- ----------------------------- <br /> ADDITIONAL' COMMENTS ------------ --------- - -------- ----------------------------------------------------------------------- <br /> --------------- <br /> ---------------------- ---------------------------- ----------- -------- ------------------- ------------------------------ --------------------------------------- <br /> ---------------- - --- ---------------=------- <br /> -------------------------------------------- /c� !e` <br /> ------------------------------------------------------------------------------- <br /> Inspectionby ----------------------------------------------- <br /> SAN <br /> - Date ----- <br /> --------------------- <br /> Finall } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M -+_ <br />