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i' <br /> FOR OFFICE USE: <br /> -`0 7_q - :BJ ----- APPLICATION FOR SANITATION PERMIT <br /> a � ... <br /> ----- --r- *- - ---(Complete in Triplicate} pate Issued <br /> ________________ ______.-_____-____.____._---________ This Permit Expires 1 Year From 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 /> I described. This application is made in compliance 1th County,*Ordinance No. 549 and existing Rules and Regulations: <br /> ADDRESS/LOVA �f --- CENSUS TRACT _wner's Name -------i---------- - - --- --------- = '1------------------------------------ s ' Phone <br /> J �I-_ I- <br /> C., 3l 7.�4C/ <br /> Addr ss 1.,�7 City ------ --- -- -------------------------------------- <br /> Contractbr`4s�Na'me�.i-I------ ----- ------- ------------------License #/ .�/"----- Phone <br /> Installation will serve Residence ,Apartment House,F1 Commercial ❑Trailer Court !❑ <br /> Motel ❑ Other <br /> Number of living units:._X; Number of bedrooms._______Garbage Grinder ai -__ Lot Size _ t � 0_-____---__ <br /> Wat Supply: Public System an ame ----------------------------------- ---------------------------- ----------------------------------------------Private <br /> Character of soil to a depth of 3 feet Sand'❑ Silt 0 Gay ❑ Peat❑ Sandy Loam ❑ Clay Loarn ❑ <br /> Hardpan ❑ AdobeFill Material ------------ If yer, type -----------------------�---- <br /> (Plot plan, showing size of lot, location?�Systern in„relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank r-,epage pit 'permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT[I—SEPTIC TANK[ Size--------------------------------------9--------- Liquid Depth -----.------------------ C <br /> .- ,. '.I� S <br /> TYPe ----I--------------- Material----^------------------ No. Compartments ------------ <br /> capacity <br /> Distance to nearest: Well _____ _ ______________ Foundation __i_.____._____.__-___ Prop. Line __:________:___---_-- <br /> T RING LINE [ ] No of%Unees Length of each line--------------------- ------ Total Length ----------- ------- <br /> 1 <br /> YP ---------- -------Depth Filter Material ___________-_____ } <br /> D' Box �_______-- e Filter Material --------- •.----- -._... <br /> Distance to nearest. Well __'____ ------------___ Foundation ___________.___________ Property Line __/__-______-_-:.___ <br /> SEEPAGE PIT [ ] Depth ____ ___ ._-_ _ I es <br /> Diameter'�________________ Number -___-_._._________ ________ Rock Filled Yes [] No 1❑ <br /> Water l.e_.Depth_____,-------------- <br /> ---------------Rock Size _ ------------------------ <br /> Distance nearest: Well ------------= ------------------------Foundation -------------------, Prop. Lihe -------- ............ <br /> � { <br /> REPAIR/ADDITION(Prev. Sanitation Pe mit#�- ---------------------------------------- Date ------------------------------ F) / I <br /> Septic Tank (Specify -=-�----------------------------- �� -----r--------------- <br /> Diposal Field (specify Requirements) --- -- a't* <br /> --------------- ---.--------- '3 - ---------------------�------------------------- <br /> ------- ------------ � ---- ----- <br /> (Draw+�xis ni a nd required addition,on reverse side) <br /> I hereby certify that I have preparedothis application and that the work Will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, a Rules and Regulations ofkthe San Joaquin Local Health District. Komi owner or liven- ' <br /> sed agents signature certifies thl ollowing: <br /> "I certify that in the performance of the work for which Nis," rmit is issued, I shall not,employ any perso� in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------- - ------------ --- ---------- - --- --------- - - --------'" �'` - <br /> 6-� _------ Owner <br /> BY --- ---------------- - Title '' <br /> (If oth n owner) <br /> A D ANT USE ONLY <br /> APPLIBUIL <br /> APPLICATION ACCEP7eD BY ______.__ �-- _ � - -�`_ <br /> CATION � -- - - --•, -- --------------------------------------------- PATE ----- --""� --~`�r/----------- <br /> ADDDINGPERMIT ISSUED . ----- ------ ------ ----------------------------=--------------DATE --------------]---------------------------- <br /> ITIONAL COMMENTS - 4-`- ` -- --- ----- ------ -•-------------------= =0. -------------- <br /> ---------------------------'------- ----- <br /> - - ------ --------------------------------------J---------------- ! <br /> ----------------- -Fr s_li. -------- ----- ---------------------- - <br /> - �. _ <br /> - ----------------- _ ,_ •------- ------------------------------ <br /> Final Inspection by: - - Date -�^/ � I- - --- <br /> Sf JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M - •- r � <br />