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4 _ <br /> Fr R OFFICE USE: I "" <br /> APPLICATION FOR .SANITATION PERMIT <br /> ---------------------------- ----------------------- Permit No. . <br /> i <br /> (Complete in Triplicate) <br /> Date Issued <br /> This Permit Expires l Year From Date Issue <br /> ---- <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.e) iM! g/R0A and Regulations: <br /> --- --- -' -JOB ADDRESS/LOCATION <br /> CENSUS TRACT -------------------------- <br /> "(V <br /> -------------------- --- <br /> Owner's Name �-- -�... — �. r .-------------------------------- <br /> ----------------- <br /> ------•--- -- Phone <br /> El•:' stir' tlC s - "f --------------------------------------------- <br /> --> .. Address - '" i - - --. City <br /> w. ----- - .� �-_ ....... �.....- ! _. 3 <br /> -,S e yam' .a <br /> Contractor's Name ------------ --------- ==-------License# ---------'-------------- Phone --------------------- -----•-- <br /> �r---- ----------- ----p------------------ - ❑ <br /> Installation will serve: Residences Apartment House Commercial Trailer Court ❑ <br /> r r <br /> Motel ❑Other , <br /> ye 3 <br /> .�,it"�r�ra. <br /> r - -- <br /> (- Number of living units:.--- -....,Number of be room ._..-Garbage Grindar tot Size <br /> ` WaterjSupply: Public System and-name- --------------------. -- y nvat <br /> dn <br /> --------- - <br /> r Character of soil to a depth of 3 feet: . Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> K — <br /> Y �HC430n ❑ Adobe ❑ Fill Material ..._ __. If yes, type ---- <br /> iPlot plan, showing size of lot, location"Rof system in relation to wells, buildings, etc.'' must be placed on reverse side.) <br /> Pr ai le within 200 feet,NEW INSTALLATION: (No septic tank-or seepage e pit permitted if pu 4 exer is&, <br /> PACKAGE TREATMENT { ] SEPTIC TANK f ] Size------------- -------------------------- Liquid Depth -------------------------- <br /> ' Type --- -------------- Material--- ----- ------- : No. Compartments <br /> ---------- <br /> Capacity: dptj <br /> -------------------- <br /> Distance to Weare Well ---- - ------------- --- -----Fodp1,}� Prop. Line Cl <br /> ` ;t ` <br /> LEACH':WG LINE [ ] No. of Lines ------------------------ Length f a ch lirye--- - -__-- ------- ---- Total Lenge , ---.---------------- 0 <br /> c` ff <br /> 'D' Box, ype Filter ata) Depth Material _ <br /> I T -------- --- <br /> --- <br /> i <br /> Distance rjo0earest:_Well -- 41 _ = - Foundation -------- -_ - --------` Property Line <br /> SEEPAGE PIT [ J Depth -r Diameter Number ---- .. _ Rock illec Yes ❑ No i❑ <br /> } _ . oc ' <br /> Water Table Depth"--_____ ____-- p <br /> -----------------Rock Size ----- ------ l0 <br /> Drstance I, :.. R Zai <br /> r ,to nearest: Well -z--- i'-------- -------_------------Foundation ,+�'1� _------ Prop. Line <br /> r <br /> REPAIR/ADDITION(Prev. Sanitation Permit.# -------- ----------------------------------- Date _.-_-..------------------_------- --------------------------1 <br /> Septic Tank (Specify Requirerhents) --------------------------------------- ---------------- --------- ------------------------------- <br /> ------- <br /> ---------------------------,- <br /> r <br /> Disposal Field (Specify Requirements) __-. - ._. �- <br /> :> <br /> - __ --- - ....._. <br /> ..-. -------- -------- `.--------'A <br /> - - ----- - -.------ - ..-_- ...-- - ._- .. _ __.__._.. <br /> _. . -- <br /> 1. <br /> r ...! _.......__ ---------------.- . .a _•-__-•_••-__--....__._.................................'+___....-__-----„---......--------------.-..------------------------.------ ..__..--- � - <br /> x ----------------------------- <br /> I ' {Draw existing and required additian'on reverse side) <br /> I hereby certify that '1 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 liven- <br /> sed agents signature certifies the_following t _� <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 Compensa n law of California." <br /> ' Signed ----------- - ------y==-----=---------- <br /> Owner. - <br /> I BY - -- ----------' ' ------------------------------------------------. Title ----- ----------------------------------------------------------- <br /> ---------------------------------- <br /> (If other than owner) <br /> ' FOR D P ENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ , <br /> E ---- <br /> - DAT <br /> BUILDING PERMIT ISSUED '= ------------ ---------- DATE <br /> ADDITIONAL COMMENTS .......- ---------------------- ------------------------------ <br /> -------------------------------------------------- <br /> E - -----------------------•------------- -------------------- <br /> ---- "------------------ ---------------- _ <br /> -------------------------------- - ---------- <br /> Final Inspection b ------ -- - Date ..L ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> g <br /> E. H. 9 1-'68 Rev. 5M - <br />