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R OFEICE USE: _ APPLICATION FOR SANITATION PERMIT <br /> �� Kermit No <br /> J a <br /> ��, (Complete in Triplicate) <br /> ---------------------------- c � p Date Issued <br /> ---------------------------------- - ------ <br /> This Permit Ex ires 1 Year From Date Issued <br /> Application is hereby made to the Sa n 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 CENSUS <br /> --------------- <br /> JOB ADDRESS/LOCATION : ----- <br /> TRACT <br /> i Phone f/- "- <br /> Z <br /> - } � ( 7 <br /> City -------- ---------Owner's Name ___-___. 1� <br /> Address ----------- ---- ------------------ f <br /> Contractor's Name <br /> L�.^eras <br /> --------- e # -------- Phone _y�6= _3�------- <br /> Installation will serve: -----=—Residences Apartment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other -----------I---------------`----------- ---- ' <br /> Number of living units:---/_----- Number of bedrooms __31--_-Garbage Grinder ___ -- ___- of Size ____?Y1_- ----- - - --- <br /> ' Private ❑ <br /> Water Supply: Public System and name i me _______I___ <br /> ' Peat Sand Laam Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Siltfl Clay ❑ ❑ Y ❑ <br /> Hardpan E] Adobe ' f fill Material ------------ If yes, tYP h f <br /> (PIofi,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 [ ] SEPTICAT NK-11' ri - Size-------------------------------------- - Liquid Depth --_---- ------------- <br /> iT e t ----- Material-_:--- --------------- No. Compartments ------------ <br /> CapacityZ <br /> # -- ------- - --1 Yp <br /> Distance to nearest: Well ------------± --------Foundation ---------------------- Prop. Line --------------- <br /> LEACHING LINE [ ] No. ofLines _--_---- ------------- Length of'each line---------------------------- Total Length ____-_.______-..--.- ------ <br /> r 'D' Box =---- `Type Filter Materia! ---------=--------- Depth. Filter Material -------------------------------------------- <br /> - - Distance to nearest: Well -----------=------------ Foundation ----------------------- Property Line _____...----•---•-•----- <br /> 1 SEEPAGE PIT { ] Depth- - -_-_- Diameter--_.f-________--__ Number ---------------------- ---- Rock Filled Yes ❑ No ❑ <br /> JI <br /> Water Table Depth ------------------'------`---------- ---Rock Size ------------------------•------- f <br /> ('Foundation-~:------ Prop. Line <br /> REPAIR/ADDITION(Prev.Sanitation'Pestance f6 rmit#Well -------L-- =_ ----- Date_�----------------------------1 <br /> ' I/ ` <br /> ._ s. ,r <br /> 3 - <br /> i <br /> -------------------------- <br /> Setic Tank (Specify Requiremehts) -" --�- y <br /> ---------------- ----- -- ' xz <br /> ------------------------ <br /> ---- }--- <br /> --------------- <br /> Disposal Field (Specify Re ufr- --- <br /> I - <br /> ------------------ <br /> -------------------------------------------------------- <br /> ------------ <br /> aired <br /> ct.��-r .7`a <br /> SP -I <br />� t'I( (Draw existi g and req addition qA reverse side) <br /> 1 hereby certify, that I have prepared this 'appllca* an and that the work will be; done .in accordance with San Joaquin <br /> s <br /> ,State Laws and Rules and Regulations of the San Joaquin,tocal'Health District. Home owner or licen <br /> Court) Ordndnces - <br /> r ; <br /> sed agents signature certifies the following: I <br /> "I certify that in the performance of the work for which this permit is issued, I sholl not employ any person in such manger <br /> as to become subject to Workman's Compensation laws of California." <br /> 1, Signed - - -- ---------------------------1----- Owner r <br /> -------- {. <br /> t t ---- Title ----------- ----� <br /> (If other t owner) I <br /> 1 ­7 <br /> FOR DEPARTMENT USE ONLY <br /> I DATE __ /_d-7 -------- ------------ <br /> i APPLICATION ACCEPTED i ' <br /> BUILDING-RERMI.T-ISSUED----------:-.--------- -- _-- ------•--------- ---------------------- ---------------------- DATE - <br /> AD TIONAL COMMENTS ............ =------ --- ------ - - - ------ - t----- <br /> --------------- <br /> {, .. ; i <br /> ------- ---- ------ ----------- --------= fi <br /> Final Inspection by: _----- - - - - -�-- ---- -- -- -` - - <br /> --------- -------.Dae .-----------1Z--? ------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C13 <br /> E. H. 9 1-'68 Rev. 5M <br />