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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> This Permit Expires ] Year From Date Issued Date Issued <br /> ---'--------------------- ----------------------- 3 <br /> r <br /> r <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 /> �� 1-R ,� r <br /> 106 ADDRESS/LOCATION .-- ---------�/-------- ""-- - - ---- - - ---- �i� ..- --------...----CENSUS TRACT --------------••---------- <br /> --- ---= -- _��� -�. ---- - -�---t--��'-+ T`.'C' ------ �------- Phone --------------------------•----••--- <br /> Owner's Name leo,. <br /> eJ `i2/ <br /> Address -- J �tY <br /> Contractor's Name ---- _---_----- - ----_-. ------------------License #��1f-3- -,-Phone _7�-��`�Sr✓ <br /> + Installation will serve: Residence P-Irpartment House❑ Commercial ❑Traiier Court ❑Y <br /> / Nt Motel ❑ Other --------------------------------------- Si' <br /> Number of living units-------F -¢ umber of rooms -_-__2-G rba a Grinder __ Lot ze --7 _--X__- -�`�----_----- <br /> ..( y _� y <br /> Water Supply: Public System and name ----------- --- - ----� C r- z ----_-- - ------------;----------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑� Silt Ej ---,Clay ❑ Peat E] Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobes `.a Material -� - If yes, typef----------- <br /> ------------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells;buildings, etc. must be placed on reverse side.) <br /> r � . <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size-------------------------------------------------------------------------------- _,Liquid Depth ----------------_...-._---- <br /> Capacity --'----------------- Type -------------------- Material---------------------- No. Compartments ............. <br /> Distance to nearest: Well ------------------------------------Foundation --------------- ------ Prop. Line ---------------------- <br /> 'LEACHING LINE [ ! No. of Lines ------------------------ Length of each line------------------__------T&al Length ____---__-.__-.._..-_-__-- <br /> 'D' Box - ------- Type Filter Material --------------------Depth Filter Material -----------------------------__-_-_.-.,-_._ kJ <br /> Ristance to nearest: Well ------------------------ Foundation ---------.----._------'_ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth ...... ------------- Diameter ________________ Number --.-.-----.___ -: Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------•----------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop: Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation jPermit# ---------- ------------------------------t_- Date --------- ------ - =. ....... r ,r, <br /> Septic Tank (Specify Requirements) - =° ``� <br /> -- ----- ------ <br /> 1 r <br /> Disposal Field (Specify Re u'rements) ----------/ ---- ` / <br /> -- ----------I -__---- - . - . -� ---------------------•---------- <br /> --------------------------- ----------_-___----------------- .---_-_-_ <br /> („Jt(Drow existing and required addition an reverse side) <br /> I hereby certify that I have preparedethis application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Stater 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, 1 shall not employ any person in such manner ' <br /> as to become subject to Workman's'6mpensation laws of California.” <br /> Signed --------------- - - ------------------ �----- ) ----------------------------------- Owner/ <br /> BY � � � --- ---------------- <br /> - Title ---t G`' <br /> r than owner)1 <br /> ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------, -- -------------. DATE .--- —-------------- <br /> BUILDINGPERMIT ISSUED ------------ - --------- ----- - -------------- ----------------------------------DATE ------------------------------------------- <br /> A <br /> D ITIQNAL COMMEN <br /> yy -- <br /> - ---------------�. <br /> -'----------------------- <br /> '------'---------- --------- -` -- ----- <br /> __-.-- ------------------------- ----'- <br /> Final Inspection by: Date __ _ <br /> - - <br /> AN'JOAQU LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M '• y t <br />