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POR OFA USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> f:........... .....:......... <br /> -� - (Complete in Triplicate) Permit No. ..-7S__/1.... <br /> This'Permit Expires 1 Year From Dots ss .. . <br /> - Date Issued /. <br /> ....................... p 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: j <br /> JOB ADDRESS/LOCATION -�I 4I.1.D. _-fc�f!?�.P� ...�r� .y.�ll�C�f��� s. .z � <br /> : 3ENSUS, TRACT . .. <br /> C►wner's Name ----.._.Phone .. ' .' '. > a°ra_. <br /> Address <br /> rj darn <br /> �,�f,�Calr/ ...... ............ City -- i....... ............ ...................... <br /> Contractor's Name -----&10i-el---------------------------------• - ..........................License # ......................... Phone ----- .............. <br /> Installation will serve: Residence N Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other------- -•-------------------- ......... <br /> Number of living units:-----/----- Number of bedrooms __a-----Garbage Grinder ----- Lot Size __,____ - t ........... ' <br /> t <br /> Water Supply: Public System and name ... ------------•-- --------- ..............................--........................ .............Private []� <br /> Character of soil to a depth of 3 feet: Sand Ti Silt❑ Clay ,El Peat❑ Sandy Loam a Clay Loam <br /> Hardpan ❑ Adobe 0 Fill Material ............ if yes,type........:...... <br /> {plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) 1 <br /> i <br /> NEW.INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ } SEPTIC TANK; ] Size..... ----------------- Liquid Depth ....�7�.�1A r� I <br /> Capacity/6010,04-L.- T e --------------- ---- Materiol�O-.t?�1-OA._ No. Compartments <br /> Ypf -t­Zit`-. .._. <br /> Distance to nearest: Well ---..._.-_.1.0.et......----- .Foundation .-. ,la` • . Pro Line <br /> P p. Line <br /> � <br /> LEACHING LINE Noof Lines <br /> ....._ _---- .� <br /> [ ] . ----------JLength"gth of each fineQ�.. 14).-_-/0Q Total Length `------•-_-, <br /> r". Depth <br /> 'D' Box ...%. Type•Filter Material/n.2 __. Depth Filter Material ..._/Q,......... <br /> _ . <br /> 1 <br /> Distance to nearest: Well ---Jsa ....... Foundation .--.--/.Q............. Property Line ... <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth ----------------_--•-•---.......•-------------Rock Size —.----------•---•--- � <br /> Distance to nearest: Wet) ---- Prop. Line p <br /> REPAIR/ADDITION IPrev. Sanitation Permit# .............. ...... . .................... Date -•-_._______..___..._._....-.--•--y <br /> SepticTank (Specify Requirements) ... ............................. ..................................................................................:--...................... e <br /> Disposal Field )Specify Requirements) --• ---•----••----•--•-•------ ------------- .......•--------._,,------- ------- .......... ------------------------------- <br /> -------------------------------.... ---• --,. <br /> --- --„ -------- - ------ -•-------, _,_.�. = <br /> IDraw 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 f <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 /> "1 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 Compe do ws alifornin." <br /> Signed;� --------- ...... . • ------------ ................... Owner , <br /> By .... ----------------------------------------------------_-`•--------_---------....: <br /> (If other than owner[ <br /> i <br /> FO DEPARTMEt USE ONLY i <br /> APPLICATION ACCEPTED BY - DATE <br /> BUILDING PERMIT ISSUED .----- :-:-DATI" <br /> --- - <br /> -­7�­----------------------- --- <br /> ADDITIONAL COMMENTS ---------------•-...--,..--.------------------------ - - = .,.- <br /> :------ --------•---- ------ <br /> E <br /> ............................--------,..............-..-»-------- •.------• .-.---,--•------•...-...--. .-,.....-......-----------..-----,----._-..................-.,..........-................ <br /> ..-.. � <br /> --------------_._............ ... ... ........ -----„_----- -------- ----..-....-.,....-`--.................._......c .- <br /> FinalInspection lay- ------------- -------------------------••---•---,.- . •. -• -------,--. ----•---•----.------•--.Date .r . 7- <br /> EH 13 2!t 1-68 Rev. 5m - �= <br /> SAN JOAQUIN L AL HEALTH DISTRICT 8/711 3M <br /> 1 <br /> } <br /> J <br />