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FOR OFFICE USE: (2 <br /> APPLICATION FOR SANITATION PERM <br /> ....`..__.......s .. IT <br /> :....:....... <br /> (Complete In Triplicate) <br /> `ter Permit No. <br /> This Permit Expires ] Year Front Date Issued Date (slued .. :'............. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> i described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> l <br /> 6 <br /> .. .. <br /> �pu+ .����P <br /> Job ADDRESS/LOCATION ?� .....CENSUS TRACT .......................... <br /> Owner's Name <br /> --• --••---•-------- ----- ........................................................:....................Phone? `ZVO. <br /> Address .. 7-Y.. ......._. � � ....... � <br /> Contractor's Name ............... 'r.....................--------License# ��7•..... PhoneV4 IW7........ <br /> i, <br /> Installation will serve: Residence Apartment House 0 Commercial oTraller Court 0 <br /> Motel ❑Other........................... <br /> ....... <br /> --•-..... 61 <br /> 1 <br /> Number of living units:_] Number of bedrooms ....� Garbage Grinder Lot Size <br /> Water Supply: Public System and name .... .. <br /> Character of soil to a depth of 3 feet: Sand'(] Silt o C#ay o Peat Q Sandy Loam o Clay Loam ❑ / . <br /> Hardpan p Adobe 0 Nil Material ............if yes,type <br /> i <br /> (Plot plan, showing size of lot, location of s�.sterh. in relation to wells, buildings, etc. must be placed on reverse side.) � <br /> NEW INSTALLATION: (No�septic..tank or seee', it erniitted if p u lic sewer is availal?}e within 200'feet,) <br /> PACKAGE TREATMENT{ ] SEPTIC TANK[ <br /> Size=.............................................. Liquidt Depth _ <br /> Capacity ---- Type .._..•--•---------­ Material...................... No. Compartments. <br /> Distance.to nearest—We'll --. A...............*._....Foundation ..._.._..........-_- Pro Line r <br /> rp. ................... <br /> ,LEACHING LINE [ ] No. of Lines ------ ................Y Length of each line.. ! Total Length ....... „ ._............. <br /> 'D'D' <br /> Box .._...:_.... Type Filte'4teriol ...................Depth Filter Material •.... ....................... ........... <br /> Distance to nearest: Well ......................... Fou dation -•---•-----.._......._.. Property Line .-....i.........:...... <br /> SEEPAGE PIT ( # Depth .................... Diameter -------.__ ..... Nu er ....................•---__-- Rock Filled Yes` ] yNo <br /> Water Table Depth ------------------------------------------ Size -..............................Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ......................... <br /> Septic--Tank (Specify Requiieh ents)- _ "" <br /> ..... ....... . ..... ....... ------ ....... <br /> r <br /> Disposal Field (Specify Requirements) --------- .. .... I .-- ce. <br /> i <br /> ... ..- r - ---------•----- ----•-•- ----•-- ........--•------------•-•--•--------------- 4 <br /> I <br /> (Draw existing and required addition on reverse side) s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin I <br /> County Ordinances, State Largs, and Mules and !Regulations of the San Joaquin Local Health:District. Home owner or licen- <br /> sed agents signature certifies therfollow➢hg: �{ LA <br /> "I certify that in the performance of the work for which is permit is issued I shall not employ an 1 <br /> y P p p y y person in such manner l <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------ - -------- Owner <br /> BY ----- Title -- s <br /> (Ifo her than owner) <br /> PARTMENT USE ONLY ey <br /> APPLICATION ACCEPTED BY---- _-.."---- DATE_-- �."3.;./-.1�r---------:- � <br /> Bt1iLDING PERMIT ISSUED ...... -1 - --- - ------ <br /> ..... - ----------.---------------------------------------- -------DATE _. -•------.._._........ ; <br /> ADDITIONAL COMMENTS ---- - ------ -- -- - <br /> - --- -- -------•-----_ ---•-- ....................................................................------._------------•---•---- <br /> ..--••-"--------------------- ----•-•... .......-.-----------------...--•--------------------••------------ ---•• ...... -............•---- •--- ................ <br /> -------. - ----•- • <br /> Final ins <br /> p ecfiion by- ------•• --- ------ -----------•--- --••-----------• —............._... •----.---- <br /> '". "~ •--- <br /> - <br /> - " <br /> .-- - -- ------------............-........_.. ------.._.-------..............Date ..__...----EH �3 2a 1-68 v SAN J AQUIN LOCAL HEALTH DISTRICT <br /> 8/74 3M <br />