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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - . Permit No: .__73-` l-2Z <br /> ..........I---------------------------------------------- <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date 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/LOCATIO - - G--- 9----4'!'� --------------CENSUS TRACT -------------------- <br /> Owner's Name f s2 (/> � --�------------- -: ----- ---Phone ------------------------------------ <br /> Address � �� � � --- - /' , City ` <br /> -_ F -�_ <br /> Contractor's Name ----- ��L1=-�-�,.a.�__: l�- _ License # ____ C�-�-`- Phone .............................. <br /> Installation will serve- Residence Apartment House-E] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ------------- -------------------------- -- <br /> Number of living units:____-t1___ Number of bedrooms ___Garbage Grinder ------ ----- Lot Size --- Tf�-��� ^ <br /> ----------------------- <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [K- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .0 Clay Loam ❑ <br /> Hardpan ❑ Adobe 1� Fill Material ------------ If yes, type ---------------------------- <br /> O <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 -------------------------- C <br /> Capacity -------------- ----- Type .------------- 7-- Mat Er' No. Compartments . •--.......--------.. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ -Length of each line----------------------------- Total Length -----_.---_._-_-__-_-_------ <br /> 'D' Box ..---------- Type Filter Material --------------------Depth Filter Material --------------- ---------------------------- <br /> Distance to nearest: Well __-___-"----__------- Foundation ------------------------ Property Line --_-_--------_-_-._.--. <br /> SEEPAGE PIT [ ] Depth -------------------- Dibmeter ---------------- Number - ---- Rock Filled Yes ❑ No C1 <br /> Water Table Depth ------A------ -- -----------=•----------- ---Rock Size ----------------------- -------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .--.-----.__-__------- <br /> REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_--____-----_--_--_-__---____-_-_) <br /> SepticTank (Specify Requirements) -------------------------------------------------- ----------------------- ---------------------------- ---------------------------- <br /> Dlisposal F' d (Specify Requirements) --- j - , ��J --T�- fx - /-•--------------- <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 la of California." <br /> Signed ------------- - - - - - - �' - - --�- --�� �1%L �OI ner---- -�-=-=--f 1 <br /> "------------ <br /> BY _ -- `} -------`------ °'',------------- --- ------- <br /> (If other than owner) <br /> J <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYC ------------------------------------------ --------------------- DATE � -774?------------------- <br /> BUILDING <br /> $�-4?--------------•---- <br /> BUILDING PERMIT ISSUED -------------- ------------------------------------------ - --- ------------------------DATE ....'-------------------------------------- <br /> ADDITIONAL COMMENTS --------------- t l- - ----- ----------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- ---------------------------------------------------------------------------------------------------------------------------- <br /> - ----- - -- <br /> --- ------ - <br /> - ----------- -- ------ -- --- - <br /> Final inspection by, Date . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />