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FOR OFFICE USE: <br /> r qLAPPLICATION FOR SANITATION PERMIT <br /> --------------------=---------•----"------=------ Permit No: <br /> Y4 (Complete in Triplicate) I- <br /> --__-___________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 /> JOB ADDRESS/LOCATION � _ : ._mom//✓ ilL: _� �Qz* � __ _ } ENSUS TRACT __________________________ <br /> Owner's a {------��9,. ------- - / -------.Phone <br /> Address f _____-- ---• city :----• •---- <br /> Contractor's <br /> Namerxr*&----------------------------License # _r --- Phone -----------------------_----_- <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court ❑ t <br /> Motel ❑ Other/ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ___________ Lot Size -------------------------------------------- <br /> Water Supply: Public System and name _ ___ _ <br /> pp Y Y -------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam K Clay Loam C) I <br /> Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system 1n 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 f ] Size__X_7X/__(*___u_.'5_&e_S�____.______ Liquid Depth —4_ _ -Z---------- <br /> Capacity 2P00------- Type Material-------- --------- No. Compartments ---------------------- <br /> Distance to nearest: Well ___,/ __e________________Foundation _1C9--_________ Prop. Line _Z�_--_`------ <br /> LEACHING LINE [ ] No. of Lines __-4_ -________________ Length of each.,line.__ 16_[x_--__--._-___ Total Length ,___? PJ. -_`__-_.__ <br /> D' Box --- ------ Type Filter Material -L_ Y2_k _---Depth Filter Material ---1� --------------- ----------- --- <br /> Distance to nearest: Well ---AIV----------- Foundation --- --------- Property Line <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------•------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...........---.__._.-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------- ----------------------------------- -------------- --------------------------------------------------------- <br /> Dispo al Field (Specify - <br /> ------ <br /> ,Requirements) <br /> _ - <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, 1 shall not employ any person in such manner <br /> as to become bject to Workman' Compensation I s_of California." r. <br /> Signed --- ------. <-=------ '`" - --- weer <br /> BY -------------------------- Title ---------------- <br /> ------------------------------------------------------- <br /> (If other than owner) <br /> FOR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --- ------ X- - '?- _ <br /> - =- ------------------------------------------------------- DATE --' X 7---- ------------------ <br /> BUILDING PERMIT ISSUED,.___ __ ____ ________r ___ DATE <br /> ---- - -- ------ ---- <br /> ADDITIONAL COMMENTS xl! Id ------- - — ``ZI <br /> - ------------- - --T-- <br /> ' - �, ------------------------------------------------,- <br /> ------------------------- <br /> ------------=------ <br /> - �- - ------ - -- ----[ ---- ------ ---------------------------------------------------------- ---------- <br /> Final Inspection b -------- ---------------------------------------Date ��y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1 '68 Rev. 5M, <br />