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FOR OFFICE USE: ..,µ a <br /> APPLICATION FOR SANITATION PERMIT <br /> Y <br /> ----------------------------------,---- - Permit No. 7h1-----..... <br /> ---------------- <br /> (Complete;in Tripllcate) <br /> _Y <br /> I Date Issued -_-f� 77Z <br /> -------------------------------------_---------------- This Permit Expires 1 Year'From 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 /> r _ _ ----------------CENSUS TRACT --------------- <br /> JOB ADDRESS/LOCATIO - -- O_._�- .,?--�-�-- _ __--`__-- _ � -----_--•- <br /> w <br /> Owner's Name i <br /> - ----------- <br /> Address y ----------------------------------------------=------ <br /> 7 - ----- -- <br /> ----------------- /� p <br /> Contractor's Name . ----- -- -- --- ----------+------.License # . 0 _0 //--- Phone 4C <br /> Installation will serve: Residence` ment House 0 C mercial :❑Trailer Court i❑ <br /> rY Model,El Other -------f----------�;-- / <br /> Number of units:..___.-__ `- r /� �............... <br /> living Number of,bedrooms ____ ______Garbage Grinder :Lot Size -�_._______.____ <br /> Water Supply: Public System,and name -_ _____________ _`_________________�.____ ------ <br /> ---------- <br /> Character <br /> -� _________.____Private ❑ <br /> ---:- <br /> Character of soil to a depth of 3 feet: Sand'[I SiIt-LDClay'❑ { Peat❑Sandy Loam -E] Clay Loam 0 <br /> i r e <br /> Hardpan ❑ Adobe_:Fill Material t_. -' - If yes,_type,.--_---_-_________________ <br /> (Plot plan, showing size of lot, location lof system in relation to wells, build+ngs;-etc.._must be pld'ced on reverse side.) <br /> I S I i ��•nr...���r+ W I s� Y a <br /> NEW INSTALLATION: {No septic tank of seepage pit permitted if public sewer.is available within 200 feet,) tJ11 <br /> PACKAGE TREATMENTSEPTIC TAN TTM r <br /> [ � K'[ ) 5ize_---�'r--- Liquid Depth __ <br /> Capacity_...-_.-------------_Type.______________----___-Material No`. Compartments <br /> Distance to n-earest:_Wbll ----------------------__------------Flour%dation---- --- ----------- Prop. Line -_-------------------- <br /> LEACHING LINE [ ] No..of Lines _____ _s°"' Length of�each..line_ "=t -__=Total Length <br /> 'D' Box -----L=-j-T5ype Filter Material Deptitter,Materiaf <br /> ------ <br /> Distance,to nearest: Well,_.__. .________________ Foundation- --y1''`�_y---__-- Property Line -____-___._______---_--- <br /> ----------- - -;'= a <br /> � '' � } 1:: f'� _ . _ _Ry_i ___ Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth— Diameter ___ Number _—_ . ._ ._a � Q IQ <br /> Water Table_Depth._--•----------------_------- =---=- --•------- - --------------------- <br /> Distance to nearest: Well ----------------------------------------Foundafion '"'� ------------- Prop. Line ---------------------- a <br /> '.. � � <br /> REPAIR/ADDITION(Prev. Sanitation Permit C# _____________ _____________________________ _Date ""--_:______________} <br /> Septic Tank (Specify Requirements) <br /> _- ^- <br /> Disposal Field (Specify Requirements) __________ �__._____ _ �__.. __f <br /> - <br /> r <br /> ! ��� X-Z = - ------------------------- <br /> ( (Draw existing and required additions 6i everse-side}- I <br /> I hereby certify that I have prepared this application and that the work will. lie—done An accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Jaaquin Loc61_.Heblth 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,�l shall notemploy any person in such manner <br /> as to become subject to Workman's Compensation laws of.California." <br /> Signedned ------------- =_ Owner <br /> +BY ------- - <br /> e <br /> Title <br /> " <br /> {If t er.than owner) <br /> - OR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- y � t = DATE <br /> /t <br /> BUILDING PERMIT ISSUED ----- ------------------------------------DATE -------------•----------- ----------- <br /> ADDITIONAL <br /> - <br /> r <br /> AD T --LMNENTS ------------- <br /> ------------------­--- --------------•---------..---------------------------------------------------------- -------------------- ------ <br /> -- ------ - ------ ---------------------------------- -------- ------- ----------------- -----------------------=--------------------------------------------------------------- <br /> - ------------------------------------------------ -- - � -------------------------------------------- <br /> Final Inspection by: ------- ------------ -------------- -- =----=--------Date _ y' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />