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FOR OFFICE USE: F <br /> - APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------- Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires ] Year From bate Issued <br /> Date Issued/off__ 0_-d <br /> --------------------- ------------------- -- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and installt he work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules ands Regulations. <br /> JOB ADDRESS/LOCATION --------J-------���_-O__.___ --- [x --`---- a-(r-±-r------ .---CENSUS TRACTS -------- ------------- <br /> Owner's Name G-'--- --- Phone ✓- _ � <br /> --- - - <br /> Address ----- -- -----------=---- ----- ------ --------- ---- City 0 ---------------------------------------------------- <br /> ---- <br /> ----------------------------`--------------------- <br /> Name ---- -- - License # ---- Phone b�6--------------- <br /> Contractor's ' -=--- <br /> Installation will serve: Residence Ed Apartment House,❑ Commercial :❑Trailer Court ;❑ <br /> Motel,Q Other ---------- - <br /> Number,of living units: ... Number of bed'raoms 3-----..Garbage Grinder"'____ Lot Size __ACRgRO�--------------- <br /> 1 <br /> !pp Y System -%. m ------Private 4 <br /> Water S.I I Public S stem and name `- peat Sand Loa <br /> Character of soul to a depth of 3 feet. Sand Silt❑ Clay .❑ ❑ y Clay Loam.1E] <br /> t Hardpa ❑ Adobe '❑ Fill Material If yes,type ___________________________ <br /> (Pl'ot plan, showing size of lot, location of system in relation <br /> to wells, buildings, etc. must be placed on reverse side.) \ <br /> NEW INSTALLATION: (No septic tank or seepage pit permed if public sewer is available within 200 feet,) N <br /> - - i <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] ).�,� Size------------------------------------ ------=----)Liquid Depth -------------------- <br /> �w, <br /> Capacity -------------------- Type -----------------� aterial------------------ -- No. Compartemts ------ .......... <br /> 1 <br /> Distance to nearest: Well ---------------------- ----__�aFoundation -------- ------------`'Plp. Line ------------------ <br /> LEACHING LINE fl] No. of Lines I------------------------ Length of each line_f4-R.---------1-.------ Total Length :--________--_--___________ <br /> `D' Bax .__ - -1---- Type Filter Material � ' 'ptK Filter Material -------- __ :--- <br /> �.�. i--- <br /> Foundafiion"'` ..z ------------- <br /> SEEPAGE <br /> _ , =T =Pro er Line _ --_ - " <br /> Distpnce to nearest: Well i. - `¢ p tY_ <br /> SEEPAGE PIT [ j Depth ___----_ -___.____ Diameter ______________ Number � __ ---------I----------- & Filled Yes ❑ No i❑ <br /> Water Table )'Depth -------------------------------- <br /> ==Rock Size - ---------------------- -- <br /> Distance to Jarest: Well -------------------------------`--------Foundation 1_- I--- Prop.,Lme ______________...._--- <br /> REPAIR/ADD1T[ON(FreJ-Sanitation Permit# ________________ t Date ___ <br /> n 1 f <br /> eSeptic Tank (Specify-Requirements)!-_LL--•_----•------------ ----------------------- <br /> Disposal Field {Specify. Requirements) -- ------ - ----- =� <br /> - ------- ------------- <br /> ------------- _ <br /> �-� - ------------------------- <br /> ---------------------------- -------- ----- - - <br /> X ` �0'- � "-- --- ----- , ---- ' <br /> q 2 r�`' ► 1 <br /> Draw existin and Ke uired addition on'iO se side) <br /> I <br /> ( g q J <br /> I hereby,certify that I have prepared this application and that thelwork will l be done in 'accordgnce 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 <br /> rlicen- <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." J <br /> Signed ------------ ---- -- ---------------------------:-- wrier <br /> ,, - <br /> BY /� -r -------------- -------- <br /> j,= Tale -; <br /> (!f other owner) ' <br /> p FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - e 7�t DATE -----f '�_jk �B <br /> UILDING PERMIT ISSUED --------------------------------------- ----------�-----------+ ---------- ------------------DATE ---------------------------------------- <br /> .� H_ X11-L ini Pa�9� >�v "? . <br /> ADDITIONAL COMMENTS L"' Cid Ltn+ - 34 r � - p-A <br /> ' `tR-,xj_4__ �Al Rr cr ---G5AADMI>-----49ft ------- <br /> 4` ROCK- -AA) iI-Ply �r3r'r_aT _ cont _c_ws - o.fC1 <br /> - -------- ---------- <br /> -- ------- _ <br /> ---- <br /> Final Inspe = ------- ------Date ---� -.__ ----- w, <br /> ---- --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />