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FOR OFFICE USE: ., <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------- ---------------- Permit No. <br /> --------------------------------------------------------- �\� (Complete in Triplicate) -- <br /> __-______________________ t This Permit Expires 1 Year From Date Issued 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 Rules and Regulations: <br /> 4/1 <br /> JOB ADDRESS/LOCATION .--c::­% <br /> DDRESS/LOCATION .-�9- r-- Awl?�; -------------------------------------------CENSUS TRACT .. ---------------- <br /> Owner's Name AI S,--- -7-v-e... 1 GAA------------------------------------------------------------Phone ------------------------------------ <br /> y� City l = --' ----------------------------------- <br /> Address --.��-���---�`�-�nJ�-�� ---------•-- ----- -- - ----------------------- ------ •- - -- --- - <br /> Contractor's Name -------- -------- - -----------------------------------------------------------.License # ----- ------------------ Phone .............................. <br /> Installation will serve: Residence OP<partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----------------------.---------------------- <br /> .. fid _/ t <br /> Number of living units:_-„,,,_____ Nuae► of bedrooms . __Garbage Grinder ------------ __ Lot Size _ _ ___ __ __________________ __ <br /> Water Supply: Public System and name :_ i4 �?d_�-_-44- ------------ -- --------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand[] Silt❑ 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 refation to wells, buildings, etc. must be placed on reverse side.) <br /> �D <br /> NEW INSTAII.ATION: (No septic tpnk:or seepage pit permitted if public sewer is available within 200 feet,) �• <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size-----------------_------------------------------ Liquid Depth _-________--.-.---____-. <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ............... <br /> _-Foundation _________________ Pro Line ___._..._....._. <br /> Distance `to nearest: Well ___ ____ p. .____._ <br /> ------------------------------- <br /> LEACHING LINE [ ] No. of b net :------------------------ Length of each line __-------------- Total Length ----------- ................ <br /> 'D' Box __ :"—' --.Type Filter Material --_____________Depth Filter ,Material ___________-_-_-_-.__-____----.-_-.-.---- <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ----- -------------- Diameter ________________ Number ________________________ Rock Filled Yes '[] No C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ______________-____----_-----_____) <br /> �t <br /> ,y <br /> Septic Tank (Specify Requirements) ------- ------- CC./---- •. . --'. "ei'�'�'— --- --- --- <br /> Disposal Field (Specify Requirements) ___ N�! -------- .... <br /> -------a-- - ------ �---------------------- <br /> lqn---�� -----------c1LA10---------------------------------------------------------- -----------------------------------------------------------------------=------------------------ <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/ s of California.” <br /> Signed � - Owner <br /> By -------------- -----------------------------------.----------------------------- ---------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> .9 Ile FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----15- - -- ---------------------------------------------------------------------------. DATE ------Z-_T'--2-4Z ....------ <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL <br /> ---------------------- ----------------ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------=-------------------------- <br /> ------------ ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> L ------------------------------------------- - ----- ------------------------------------------------------------------------------------------------------------------------------------------.-- . <br /> --------------------------------------------�j► --------------- ------------ ------------- ------------- --------------------------------------------- <br /> Final Inspection by: ------------1 -------- -----------------------------Date ------ -.---T'"-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />