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FOR OFFICE USE: A <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- ------ ------------ -- -- r / <br /> {Complete in Triplicate) <br /> Permit No: -----7y-------- <br /> -------------------------------------------- <br /> ------------------------------------- . <br /> -- <br /> This Permit Expires f Year From Date Issued d 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 <br /> Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRES9JLO�'ATj-0N .� ... _ " r��1� F✓ ~- CE <br /> :. N RA <br /> SfJS T CT _ <br /> Owner's Name / ` -�1 ---- ---- ----=--------------------------- -------------------Phone <br /> _ ,�y <br /> Addressr `` � a 1� -------------- City <br /> --------- <br /> _ s <br /> -------------------------------------------- <br /> c� <br /> Contractor's Name ------ -.--��._. Cl� ----------------------------------------License # .i.-_ 2--- <br /> Installation will serve: Residence ®Apartment House°E] Commercial : Trailer Court ;❑ <br /> Motel ❑Other ------------------ <br /> Number of living units:_.------ Number of bedrooms _____Garbage Grinder ------------- Lot Size ________ _____________.___ ......... <br /> Water Supply: Public System and name --------------------------------------------------- ------------------------------------------------- --------Private <br /> Character of.soil to a depth-165f-3-fe—ef,7—Sfrn-d'E]--Silt-❑—Clay -❑—Peat-O Sondy•-Loam X Clay Loam :❑ <br /> Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ____________i______________ <br /> (Plot plan, showing size 'of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> C NEW INSTALLATION: (Noseptic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> _ F <br /> PACKAGE.TREATMENT [ ] ;:SEPTIC TANK'[ ] Size----------------------------------------------t Liquid Depth .--------------------.---- <br /> Capacity --------------------- Type -------------------- Material.--------- --- ------- No. Compartments ----------------------- <br /> I <br /> Distance,to nearest- Well ____________________________________Foundation --------- ------------ Prop. Line __________...___.__:._ o0 <br /> I I <br /> LEACHING LINT: [ ] No. of Lines ------------ ----------- Length of each line---------------------------- Total Length ---------------------------- <br /> Box ------ Type Fitter Maierial --:----------------Depth Filter Material -------- -----------------------•---- ---- � <br /> Distance to nearest: Well -----------------------`'Foundation ------------------------ PropertyLine ----------------- --- <br /> SEEPAGE PITT ( ] Depth ------------- _ ',Diameter -------------=�rNumber ---------------------------- .Rock Filled Yes ❑ No i❑ <br /> ! Water Table Depth i-------------------------- == Rock Size --------------------------=--- <br /> I REPAIR ADDITION(Prey. Sanitation nearest: Well _ "' -._______-__Foundation � _4_ Prop. Line ___________________ <br /> Distance t <br /> / n Permit'# ------- --------------------- --- Date <br /> --- - --•--------------------------- <br /> ic Tank�(Specify <br /> stl _ .. 1# ! t <br /> ---------------- <br /> Disposal Field (Specify Requirements) -__A _____s�___ ^, <br /> _______ <br /> I <br /> - --/-1-J-----------._ <br /> ------- <br /> ----------------' ------I-------------------------------------- <br /> ------- ---------------------- ---- <br /> d. .. ---I--------------- --I <br /> ` (Draw existing and required addition on reverse side)-----' <br /> _--+.--.- -n..r..-.. .�.r - -!-tie+. -—r:,..• .p.,,�,..�.��.._^...F. �....-�wr.`..•.r+- .r..-��. <br /> P f hereby certify that I have prepared this application and that rule work will be done in accordance with San Joaquin <br /> County Ordinances, State-Laws, and-R�nd-�Reg ilations of-the%'Sian Joaquin Local Health Distiia. Home owner or licen- <br /> sed agents signature cestifie,4he following °---- <br /> X • <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 /> k as to become- b'ect t kmanompensation laws of California." <br /> Signed --------------- <br /> -- Owner <br /> By -------------- Title -------------------- - k <br /> - ----------------------------------------------- <br /> (if other than owner) <br />( l FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ---- ------------ -----------------=-----------=--------------- DATE f `7� ------•------ <br /> BUILDING PERMIT ISSUED --- ------------- - -------------DATE _-------`_---- <br /> ADDITIONAL.COMMENTS . = �" - ` <br /> - <br /> -- -------------- -----------------------------------------------------------------------= <br /> - ------------------------------------------------------------ ----- <br /> ---------------------------------------------------------------------------------------------I----------------------------------------------------=------------------------------------ <br /> ---------------------------------------- <br /> ------------------------------------------------------- <br /> -Date --- ------3_.C2__ 7 <br /> Z- 1-- <br /> r <br /> Final Inspection b <br /> P Y' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev.' 5M <br />