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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> �o --%O <br /> Permit No <br /> II. lComplete�,`i�n�riplicatdl"� <br /> =-----------------------------------------`I-- " -�' ` Date lssued�-c—M-Z. <br /> 1I This Permit Expires 1 Year from Date-issued <br /> ----------------------------------------------------- -_...,.._ , <br /> Application is hereby made to the San Joaquin Local Health District fcfr a permit to construct and instal I-the-work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br />! ----------- -----CENSUS TRACT - .---------------• ------ <br /> DRESSjLOCATION,�----- - <br /> Owner'Ds- Name . `'�'� - - ---- -----•------- .-- y-- <br /> Phone-����O 3 3..---- <br /> -----. City --- ---- -- ----------------- Q� <br /> G AddressL'1�- ---- ------ - ---=--- t 7 <br /> Contractor's Name -------- •- .�PJN�� ---.License #l0�? ��-- ----- Phone �6 - 6•{----- <br /> Installation will serve: Residence (Apartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> I Number' of living units:.-- ------- Number of bedrooms --/-------Garbage Grinder ------ ----- Lot Size ----_-_ -------------------- ---------------- <br /> IM <br /> Water <br /> pplY: Public System and name ------------------ ---• - ------ ------ ------------------ -------------•-------•--------- <br /> Private <br /> ' + . <br /> Character of oi,l to a depth of 3 feet: Sand'❑ Silt El Clay .❑ Peat E] Sandy Loam Clay Loam A <br /> Hardpan-k�] hdobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showin size hof lot, location of system in relation to wells: buildings, etc. must be placed on revrse side.) �. <br /> i <br /> NEW INISTACLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> il: --- Liquid Depth --------- <br /> Size q p <br /> PACKAGi .,TREATMfNT {��] SEPTIC TANK'[ ] - - - - - - - <br /> -------- -------- Type -------------------- Material--- --- --- -- - No. Cp ments <br /> -- <br /> Capacity <br /> f ---------------- -- -----Foundation ---" Prop Line --.. ----------•-- <br /> i <br /> I DistAce to dearest: Well <br /> > iy <br /> NG LINE [ I No. of Lines ----------------------- Length of each lintel' -- ----- --- ------ T tal Lerigtii -----------i----------------- <br /> LEACHI,! 'DBox - --- ..- Te Filter Material --------------------Depth Filter Material n------------------ 1----••----•-- <br /> Mw�aiw-n-. - <br /> iDistance to nearest Wel Four ndat bn 'rope JU a ------ -----------•----- <br /> SEEPAC3lf PIT [ 1 DeP� ter ---------------- Number ---------------- Rock Filled Yes ] No I❑ <br /> ! Efi <br /> `�` - Rock Size - <br /> ' faterldble <br /> r....�.� <br /> Distance t In��ea`"esfWell ------ Foundation -------- Prop. Lir1e .... ... ------------ <br /> fi"AMi'AMTil ON(Pr 6v,.Sanitation=Permit# ------ ------------------------------------ Date _--_----__-----------------------) <br /> i <br /> p c Tank (Specify Requirements, ------------ -------------------------- ---------<-----------------,-.------------------------- @ <br /> ' Disposal Field (Specify Requirements) -----------A-�--- y - -------- - -----------0---------------------------1--•--------------- <br /> iM' "f �'` ----------------- <br /> f �.: ------------- --- ------ -- --------- <br /> ------------ -- ------------- ---------- ----- <br /> - ----------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> i �1`e"' certify tfia`t 1"have.,prepared,t�is app i(catlon`and that the work will be done 1n accordance witEr�5 n Joaquin <br /> County;Ordinances,`State res,a d�'Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies tiie�following: <br /> "I certify that in the performance of-thJ work for which this permit is issued, I shall not employ any person in such manner <br /> as to become sub(ect to Work'iFtian's Corhpensation laws of California." <br /> ..—rr. .— y }.a.� .�:o. <br /> Signed -- -- --------------- ------- ------- --------------------------------- Owner <br /> ----- --- --- <br /> BY r------- --- - ------------------ <br /> . -- Title ---- ------------- -- ---- ------- <br /> (If other tn" owner) <br /> i FOR DEPARTMENT USE ONLY <br /> APPLIC p ------, DATE --3G-'7a------------------ <br /> 'ATION ACCEPTED, BY __-___ 7�-.-�f --------------------- --- <br /> BUILDINGPERMIT ISSUED --------------------- --------------------------------------------------------------------`-- -----------DATE ------------------------------ <br /> ADDITIONALCOMMENTS - --------------------------------------------------------------•------------------------------------------------------------------=--------------------------- <br /> -------------------------- ------------------------------------------------------------------------------------- <br /> ----------- <br /> ------------------------------------ <br /> ------ -- ------------------------------il---------- - - _----------------------------- ----- ------- <br /> ---------------------------------------- <br /> Date <br /> Final Inspection b SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9i. 1-'68 Rev. 5M - <br />