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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT - <br /> lCompletein Triplicate$ Permit No. 5............. <br /> ---------------------------------------•--•-••------•----- <br /> ..............-.......................................... This Permit Expires 1 Year Front Date Issued <br /> Date Issued .5r�2'.�5.. <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/LOCATION f -._�� -. -� .�� / �ryT G ,CENSUS TRACT ....................... <br /> Owner's Name / nl� - s �� �................................. ...................................phone . .... <br /> Address . _ .. .:. _. �t/ELG <br /> ��.3... ....� .. ------------------•_.......--•---.. City ....��1.�.TSG...�................_................_... <br /> Contractor's Name .._........- -•. ���' .....:.......................License # Vie ` Phone .$ <br /> Installation will serve: Residence 1%Apartment House t] Commercial❑Trailer Court 0 <br /> Motel ❑Other............................................ <br /> Number of living units_____________ Number of bedrooms ............Garbage Grinder ............ Lot <br /> Water Supply: Public System and name ----- -------------------------•------....---•-•---•--.....................................................Private, <br /> Character of soil to a depth of 3 feet: Sand{] Silt❑ Clay ❑ Peat❑ Sandy loam.0 Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 Fill Material ............ 1f yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in +elation !o wells,,ktAldings, etc. must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public <br /> /sewer is available within 200 feet,j X <br /> PACKAGE TREATMENT [ } SEPTIC TANK f } Size.- ............ Liquid Depth ... ............. <br /> Capacity ---- Type I e&f2g1 Material...................... No. Compartments ...�............ <br /> F - <br /> Distance to nearest: Well ----9- ..................... <br /> `4.9 .......................Foundation ./._1�...1......... Prop. Line ..��-� .1f <br /> !EACH <br /> > v <br /> IN [ ] . _.- .............. geach line.__'� cr�.��'.`. <br /> ._�._.........._ Total Length ... . ........,J <br /> ,..G LINE Noof Lines Length of` / <br /> 'D' Sox ....�_..-. Type Filter Material -Depth Filter Material ........ ......... .._ O <br /> Distance to nearest: Well,..P ..... Foundation .................... -PropertyLine ...Z,............ <br /> SEEPAGE PIT { ) Depth -------------------- Diameter ..........--•... Number ............................ Rock Filled Yes ❑ No ❑ V) <br /> Water Fable Depth ................................................Rock Size ._..................I--•-...... <br /> Distance to nearest: Well ............................. ..........f"oundation .......... ......... Prop. Line ..- ......--.........� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........._-----------------•---_-------.._.. Date ._...___.............__...........) <br /> x � cSeptic Tank (Specify,Requirements) --•........................ .................... .......... .................. ...........................••..................... t� <br /> DisposalField (Specify Requirements) ------------------------------------- ................. ........ -----------......................................................... <br /> .� <br /> ---------------------------------------------•-•-------------------------------•-•----------------------------------------- ......................... ...............................................it <br /> -------------- ------------------------------------ -------------------------------------------------------------------- ---------------- ---------- ................................................... <br /> ' (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepgred_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. Horne owner or Ilcen- <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 ;bje o Vy�grkma 's Compensation laws of California." <br /> Signed ......-----•. ...................................... Owner <br /> �. <br /> SYa - Title . ....................... •....- .................................. <br /> (If other,than owner) <br /> FOR DEPARTMENT USE ONLY �+ <br /> APPLICATION. ACCEPTEDgY .................................... DATE . .fix- `�.' ------------- <br /> BUILDING PERMIT ISSUED ---------- ------------------------------------------------ ....................DATE ...............------------------AD T10NAL COMMENTS ------------------------------------ <br /> -- -- - <br /> 'ke., C: ... _ -Xj -- -- <br /> - .. _... ....----•-----------•.................... <br /> - -- - ------ ---- <br /> ----------------------------- <br /> Final Inspection by: -- - -- ------- -- ---- -- Date _.....-.... ° ---- -?V-------------- <br /> -- <br /> EH 13 2? 1-•68 v. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/Ili 3M <br />