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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ��- 6 7d- 3:00 <br /> Permit No. <br /> (Complete in Triplicate) - <br /> � 7 <br /> -------------------------- •_---„------------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> N_e; " % - CZE k i \ <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> 10B ADDRESS/LOCATION .-(/ Sr-�-r�� --- v, - CENSUS TRACT <br /> - - vw fw ---------------------------•---- ------- --►- <br /> ----Phone ------------------------------•--•-- <br /> Owner's Name <br /> Address - - -� a d s'------ -----/------- CitY <br /> ` ' , / ' 3-`---f---------l•-y-- <br /> --- <br /> Contractor's Name --- 1�-�--�� 1P----------------------------------------- <br /> License � Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court 'Cl <br /> Motel ❑Other ------------------------------------ �� ) <br /> Number of living units:_________ Number of bedrooms _____Garbage Grin deri------------ Lot Size _X °_ _____________________ <br /> Water Supply: Public System and name ----------------------•--------------- ---- -------=--=------------------------------------.....-------Private Ic I <br /> t <br /> Character of soil to a depth of 3 feet: Sand's Silt❑ 1 Clay ❑ Peat❑ Sandy Loam [❑ Clay Loam ❑ <br /> - Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ---------------------------- <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 ---------------._----,-_--_ <br /> � i <br /> Capacity -------------------- Type ---------- --------- Material---------------------- o. Compartments ------ - <br /> r I Distance to nearest: Well ---------- ------------------------Foundation ------ --------------- Prop. Line ---------------------- <br /> LEAC HING LINE [ ] No. of Lines ----___________________ Len h of each line-----------------__-. -_ Total Length .----_-----.-.....-_.___--.__ <br /> 'D' Box ------------ Type Filter Mat ial --------------------Depth Filter aterial -----------------------------•---------.__-- <br /> t Distance to nearest: Well --- ------ ------------ Foundation --------------- -------- Property Line --------_-----_--.-..:-_ <br /> SEEPAGE PIT [ ] Depth Diameter Number ---- Rock Filled Yes ❑ No ❑ <br /> --------------- - - <br /> Water Table Depth -_--_-____- <br /> Rock Size ---- <br /> iDistance to nearest:aWell -------- ------------------------------Foundation -------------------- Prop. Line ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------- ---------------------------- Date ----------- ---------------------- <br /> Septic <br /> _----__-_ -Septic Tank (Specify Requirements) ----- ----------- ------- ----------------------------f------------------- ------------------------------------------ <br /> Disposal <br /> ------------------------------- •-------- <br /> Disposal ��jjield {Specify Requirements) ------ -----------&A-------1L-�,�-C---------------�L_N- - ---------. <br /> L.cJ�- Q------------------------------------- ----- I----------------------------- - <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 /> '-'1 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 subject to Workma 's Compensation laws of California.” <br /> Signed ----- - ------ <br /> ----S------------ -- ----I - - --- Owner <br /> BY =---------- `--------------- --- - - ---------- -------------------------------------• Title --------- <br /> (If other than owner) <br /> �Fr^OR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY -- -` 0'_- _,�.... a------------------------------------------------------- DATE -----tlG--' - --."- D <br /> BUILDING PERMIT ISSUED ----------------------- ------DATE -------------- <br /> ------------ -------------------------- <br /> ADDITIONALCOMMENTS --------- ---------------------------------------"----------------------•---------------------------------- ------------------------------------------- <br /> J/ <br /> ------------- --------------------------- I <br /> r----------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ ------------------------------------------------------ --`--------------------------------------_ <br /> ------- -._.. '" '---------fir - ------------------------------. -`-------------- <br /> -------------------------------------------- -- --- - - - <br /> Final Ins ection b -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />