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-<FOR OFFICE USE' y ` <br /> a ' N ; APPLICATION FOR SANITATION PERMIT <br /> - - -------------------- <br /> -E - (Complete in Triplicate) <br /> Permit No: -_-__- <br /> -- 19� - b p <br /> -----------------------------------_--- ---------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the Sate Joaq'jin Local Health District for a permit to construct and install the work herein <br /> described. This application is made <br /> d� in compliance w' ounty Ordinance N 49 and isting Rules and Regulations: <br /> JOB ADDRESS/LOC TIO G -Q-- -,� CENSUS TRACT --------------------------- <br /> C <br /> ___________________ ... <br /> Owner's Name - -- - - -------------------------- <br /> ------- --------- --- ho e .------------------------------- <br /> VW <br /> Address�0_6 Q. ------ City . . ............. <br /> .................._ <br /> • ___.License # yU� Phone 7- -7 <br /> Contractor's Name _ q <br /> f <br /> Installation will serve: Residence y partment House-❑-Commercial ❑Trailer Court i❑ <br /> Motel ❑Other --------------------------------------------- <br /> Number of living units:_.--- --- Number of edrooms ___ ___Garbage Gr' der Lot Size _ __ --________a_ --------- <br /> Water Supply: Public System a6d name _---_ _ _-----[�,1- ;------- - Private El <br /> 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 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,) a <br /> - , <br /> PACKAGE TREATMENT [ ] SEPTICTANK Size__ _�__�- _�-�-------___-- Liquid Depth ___� __ <br /> __ _________________ <br /> Capacity _/j;kS-d--- TypeP�_4/pO _ Material_64_)_LC-------- No. •Compartments ------ <br /> A <br /> ----- <br /> `� _Foundation __ ___ Pro .,Line ___. -------------- <br /> Distance <br /> to nearest- We11 _ __ /�?- Wil__-- p. <br /> ----- - ---- ---- - ------- <br /> p, tt i <br /> LEACHING LINE No. of Lines -------� --- Length of each line---C !1_______________ Total Length ---- --4................ <br /> 1 <br /> 'D' Box ------------ Type Filter Material S1_,�?dC*bepth Filter Material ------ ----AT-------------------___........ <br /> E Distance to nearest: Well ---'# Foundation __/40--- Line +�__�.• <br /> Depth _____-_ Diameter Number _____..___ __ �..._�-_ ,RoCc1t•FiIIec1 Yes No I❑ <br /> SEEPAGE P17 Water Table Depth _______-----------------------------------------�� Rock Size_+ �� J <br /> Y�. <br /> p ----;------- --•,--------- <br /> f <br /> Distance to nearest: Well ________________________________________Foundation ____'______________ Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------_----1 <br /> SepticTank (Specify Requirements) -------------------"----------------------------------------------------------------;-----------------------•--------------------------------- <br /> i <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------------------=- ------------------------------------ <br /> ------------------------ ----------------------------------------••------------------------------------ ----------------------------------------1-1-­--------- <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 ihei'San Joaquin Local He7alth 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 /> i Sign d ------- ------ Owner <br /> _ 4 s <br /> _ , itle __ <br /> ---- P44tz z(---------------- ------- ------------ <br /> BY - i <br /> (If other than owner) • <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY E --------------------------•--------------------- ----------------- DATE - 6 y ----------------- <br /> BUILDINGPERMIT ISSUED -------- ------------------ ----------------------- ---------- -----------------------------------DATE - ----- ---------------------------------- <br /> 1 ADDITIONAL COMMENTS ---------------- -- ------------------------------------------------------------------------ -----------------------------------------•---------------- <br /> + --------------------------------------------------I----------------------------------------------------------- ----------------------------------- ---------------- ----------- ----------------------- <br /> i <br /> ---------------------------------------------------- <br /> _ <br /> ------------------------------------------ <br /> Final Inspection by: _ ti+ £��------------------------------------------------------------------------- --------------- -Date _ _ _ 7 .e`i - -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> E. H. 9 1-'68 Rev. 5M <br />