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FOR'OFFICEsUSE: APPLICATION FOR SANITATION PERMIT <br /> ------- ------------------------------------------------ -_ Permit No. "- ------------ <br /> ------------------ <br /> (Complete in Triplicate) .- <br /> ---------=------- -- ------------------------------------ <br /> -1.4 /1Date Issued <br /> --------------- ---- -------------------- <br /> 'ZThis„_Permit-Expires 1 Year From Date Issued: c <br /> {3`? v s I <br /> al Health District for a permit to construct and install the work herein <br /> Application is hereby made to the San Joaquin Loc <br /> described. This-application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -�,----- f �-- -----------------------CENSUS TRACT ------�J--------- -1--- <br /> Owner's Name -----/ '�� ��--------------I----------------------- - r ------ Phone "",t -3 _{ <br /> _ ---------------__- CitILJf 1- a ------------------------------- -------_--------------- <br /> Address �--"-�-� `��-----��-- ray-�---N----���"---- -- .� <br /> Contractor's Names�=. /9 �f/-/!�------- ------------------- License #O�_ r �` =" Plione `" " <br /> Installation will serve: Residence PgApartment House-E] Commercial [-]Trailer Court !❑ <br /> t Motel ❑-Other ---- - r <br /> ] Garbage ; 4-� <br /> Number of be loins _",� g Grinder ------------ Lot Size ""l��a <br /> Number'of living units:"_"�__"" - �`"-"-"----"---•'"""""""""""" • --• <br /> Water Supply: Public System and name ----__--" __-----_---"___ Private [9 <br /> Character of soil to a-de th.of 3 feet:F Sand'[� Siit x <br /> p � Clays❑ Peat❑ Sandy Loam •[] Clay Loam <br /> _a Hardpan ❑ Adobe <br /> El ------------ If es,type <br /> e <br /> sem_ ry "• <br /> {plot plan, showing size�of lof, 'Icicationrof system;-ira--relation to veils, buildings, etc. must beplacedon reverse side.) <br /> NEW INSTALLATION: (No sept c tai''or seepage,pit•permitted if public sewer is available within 200 feet,) <br /> w FSize�" --------------------------- Liquid Depth ---------------•---------- <br /> "^► <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] <br /> �.- ~Capacit ---- ---- Type -------- --------- Material_ N Compartments ---------•------- <br /> p <br /> Distancelto nearest;_ Well' _-_ �___" _-----�---Foundation _------_- ----------- Prop, Line ---------------------- <br /> 1 <br /> ------- --------- § <br /> s n t. E �- t <br /> LEACHING LINE [ ] No. of Lines - -� Leng h of each line--.-------_--------- ------ Total Length ---_---_-_-,--_-_____-_---- <br /> - Depth Filter Mat rias __--_"""-_-_"_" <br /> 'D' Box t °--- Type Filter Materi I -------------- P ----------------------•------ <br /> J i <br /> Distance,,,to nearest: Well ------ -�'--�"'�Foundation -____-------------" --- Property Line """__."""" ..---:---- <br /> SEEPAGE PIT [ ] Depth th --------- Diameter -' ----------- Number ------------------- - -- --- Rock Filled Yes ❑ No .0 <br /> Water Table Depth --------------------- <br /> ------------------------Rock Size ____-_--- -------------------- <br /> It <br /> =+ ' <br /> p <br /> --------_-- <br /> Distance toriearest: Well --------""--- -- ------------- - ------Foundation ---" Prop. Line -------- <br /> REPAIR/ADDITION(Prev. Sanitation ,Permit# ...I---------------- --- -----------------" Date ------------------ ---------------1 <br /> Septic Tank (Specify Requirements} ---------------- '""...�--------------- ---------------------------------r------ ---------------•----------- <br /> Disposal Field (Specify Requirements) ---------------- �s ---------------------------------- <br /> -----------------------------` - <br /> ------- - <br /> yr <br /> - <br /> ------ <br /> _ .. �, <br /> -------Mew"--�--- �_� _ S ----- ". <br /> _ <br /> - <br /> ------- ct-----X.en-a-4--- <br /> (D'raw existing and required`addition on reverse sidy� <br /> I hereby certify that I have prepared)this-application and that the work will be done in accord n�c�e�wi San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. tJ ner 'r licen- <br /> sed agents signature certifies the following: I ftt11 / <br /> g <br /> "I certify that in the performance of the work for which this permit is issued, I shall note/Ploy any peysoi <br /> 1t� n such'manner <br /> as to become subject to Workman's Compensation laws of California." �/"��✓ ��1 �/ <br /> Signed =- -- --------- - -----------------------.--- - ------------------------ Owner U <br /> BY <br /> r !.,-� . Title <br /> ---------------- <br /> ----------------------------- <br /> Of o#her than owner] <br /> t FOR DEPARTMENT USE ONLY F <br /> APPLICATION ACCEPTED BY ��. --0- ------------------------------------------------------------F-------- --,--- DATE �' ----------------- <br /> BUILDING PERMIT ISSUED <br /> --------- l k -R--------- ------ -------'--------------/--»-- --------- -------------------------------DATE S-J-T--A---Ti----(--O�- <br /> ADDITIONAL COM ENTS 2C4 ------------ -----�-----�' 1jn � p- <br /> -r rct ---N fTt "EtPE JG---- CA �----- -------Y <br /> - <br /> _-- -------=--------- <br /> - -� --------- <br /> R:X f <br /> Final In's ------------------ ----.Date - <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />