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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..................... <br /> _ z <br /> . . ........................................... <br /> O (Complete in Triplicate) <br /> ...... _........................._................. This Permit Expires i Year From Date Issued <br /> Dote Issued .3_��.�.7 <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:JOB ADDRESS/LOCATION ....//3 _ /....�,1.cc!.._ ............. ........� ..............CENSUS TRACT ............ ............. <br /> . . ... ......... . <br /> i <br /> Owner's Name ......... lle.x..... -----------------------•--....... ......... Phone .................................... <br /> Address . .... . . <br /> ll-��.l.---..�---�-- - . . .....................................City //�Gs <br /> Contractor's Nome .. G. L.. .. Y!..��'Pt'!G�1�C.�L'....................License # Phone�..���.9� <br /> Installation will serve. Residence A Apartment House Commercial (]Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:.. .. Number of bedroom: . .....Garbage Grinder Lot Size .... r�s.��S'�C`/7tr..S..... <br /> Water Supply: Public System and name ......................••-•------...__............_...........................................................Private <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam 0( Clay Loam [] <br /> OordponX 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 /> Capacity ... Type eZICC'}. ... Material lll.No. Compartments ....... <br /> Distance to neareshQQ'well 4 p .;L..�... -Foundation �................... Prop. Line ......... ............ <br /> LE G LINE ( ) No. of lines ------.--- y.. Leeach line....... .......... Total Length ��..._.........__. <br /> D' Box J?.... Type Filter Material .,/ ............Depth Filter Material ......, ..................... <br /> Distance to nearest: Well ...... Q ....... Foundation ..../<:V�........ Property Line ....��..... . <br /> SEEPAGE PIT ( j Depth .................... Diameter ................ Number ._.... ..................... Rock Filled Yes ❑ No <br /> WaterTable Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line .................. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date ..................................I <br /> Septic Tank (Specify Requirements) ........................ ! /............-.-e...---........_................---....._..----•.--........... <br /> Disposal Field (Specify Requirements) ----------8 x... ............./C7 4: , ....... p <br /> .......-.... .............................................. <br /> ..... -•...... ........�D / ___ _. LD........� N ...---• - t7_.G- ......w...`-r�/�....-......................... <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. Horne owner or Ucow <br /> sod 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 .... Q,�... ........................................ Owner <br /> By ....................................... litle ------........----•---•---....._.......-----............_............. <br /> (If other than owner) I <br /> FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY... .......... .. .. ........... --..._..... .................................................... DATE .... ................ <br /> BUILDINGPERMIT ISSUED ................................................. ......................................................DATE ........................................... <br /> ADDITIONALCOMMENTS ................................................ ......................................................... <br /> ........... ............. --...---....................................................---................................_.......................................................•--•-•.................... <br /> ....................................................... <br /> ......................................... ....... ..... .. ...... ... .. • ........................................ <br /> - <br /> Final Inspection by Dote . �� <br /> SAN JO UIN LOCAL HEALTH DISTRICT <br /> E. H.13 241.'68 Rev. 5M 7/'72 3 M <br />