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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. l <br /> --------------------------------------- <br /> (Complete in Triplicate <br /> -------------- Date Issued <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 Ru15s and Regulations: <br /> ADDRESS/LOCATION -___ AIJlf' <br /> -- ------- - -------------- r I� <br /> J08 ADD ,,.��// - (,� Q- S'� �� -------------------Phone--------------------•--------------- <br /> Owners Name I---- <br /> G� f <br /> Address -----lv-� / � e City <br /> �� � <br /> � Y ------.License #d�7f- ------ Phone ----- - <br /> Contractor's Name ----[. !_. -,. 1'9 �� ---`- ---------- <br /> Installation will serve: Residence ❑ Apartment House Commfercial :❑Trailer Court ;❑ <br /> Motel 0 Other ----37L, __0.0 L------------- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder _._____-___ Lot Size ---• <br /> IPrivate <br /> Water Supply: Public System and.name ---------------------- ----------_-------------- -------------------------------- <br /> t Peat Sand Loam Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: Sand'( Silt❑ Clay ❑ ❑ Y ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ if yes,type __________________________- <br /> (PlotpIan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 'J <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f } S• e-------------------- ---------------------- ---- Liquid Depth -------------------------- <br /> Capacity <br /> -------------- ----- A <br /> Capacity ---- ---------- Type - ------- - - <br /> ----- Material---------------------- No. Compartments -------------•.--•---- <br /> Distance to nearest: Well ------- - ----------------- Foundation ---------------------- Prop. Line -------.-- <br /> LEACHING LINE [ ] No. of Lines 9 line--------------------------- Total Length ,------------------------- <br /> ---- ------ - -- - -- -- <br /> _ en th of each <br /> �4 <br /> 1� --_----____ __-De Depth Filter Material ----------------------------- <br /> 'D' Box _______-.__ Type Filter atena ------ pi <br /> Distance to nearest: Well _________________ <br /> ------ Foundation --- Property Line --------------•--------- <br /> i ____ Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth ---- Di meter ________________ Number --------------------- ❑ <br /> WaterTable Depth -- -------------------------------------------Rock Size --------------------- -- ----- <br /> Disfiance to nearest: ell ______ __________________________ <br /> -------Foundation ----- -------------- Prop. Line ._.-------- --•---- -- <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------_------------------------------------ Date ----_---------_-------------- ) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------- ------ ---- -----.-------- ---------a <br /> - Z_X--------/�i0 e------ ----- <br /> Disposal Field (Specify Requirements) ___- - ---------&0_0------f�+--- <br /> , , may , <br /> ------------------------------ ----------------------------- <br /> ---------------------------------------------------------------------------------- <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 /> "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 subject to Workman's Compensation laws of California." <br /> Signed _ -- �_-- Owner <br /> ------------------------------ <br /> ' ------------ Title ----- ------�- ---._ ---------- - <br /> - ---------- - ------------------- <br /> ---------------------------------- <br /> i BY <br /> (if other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- t '-- --- - ----------- ---------------------------------- ----- <br /> DATE r7c7 <br /> BUILDING PERMIT ISSUED---------------- -------DATE _ ---------------------------------------- <br /> ADDITIONAL COMMENTS &----I ��h»urvc-----------------------------------------j ' - frYG- <br /> ----------------------------------------------------- <br /> ---------- <br /> ---- -------------------------------- ------------------------- <br /> -- <br /> - - -------- ----------------------------------Date - <br /> Final Inspection by: --------- - /-,�'�--� --------- ------ - - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />