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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> -------------------------•-------------------- <br /> . 7- ----------•--- <br /> ' [Complete in Triplicate . <br /> Date Issued --- - ".�:-7-.. <br /> This Permit Expires 1 Year From bate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with <br /> rCounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-_� -a__a �3----- A�-� L?-----Ro---- ------ -704C -----------"" ------CENSUS TRACT -------------------------- <br /> + <br /> Owner's Name ------------------ - M" ------------------------------------- ----;---=- ------ -------Phone ----------------------- --------- <br /> -- <br /> Address ----------- `�3 ---luk----- gll l_CQ---f%------------------------------ City -AIi'-lx-, ------------------------------------------------------•------ <br /> -----License #a?193�a------ Phone --------------------------- <br /> Contractor's Name --------�L -C.QSi�---- -------------- ------------- ----------- , <br /> Installation will serve: Residence partment House,❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- } <br /> Number of living units:------ Number of bedrooms -----3---.Garbage Grinder --__ -_ Lot Size ___-1L2- __---""--------------•----- <br /> Water Supply: Public System and name ---------------------------------"----------------------------------------------------------------------------Private ❑ I' <br /> Character of soil to a depth of 3 feet: Sand'❑' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> 1 <br /> Hardpan ET' Adobe ❑ Fill Material ------------ If yes,type --"--------__-------------- <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.? 4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ---------------------.---- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- IJ <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- ------ <br /> twi <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line------------------------ --- Total Length .-----------------------•---- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------•-------•• S <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------.-.----------- / <br /> SEEPAGE PIT [ ] Depth --- Diameter ---------------" Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- 0 <br /> Distance to nearest: Well ------------------"---------------- <br /> ----•Foundation ------------------_. Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# "---------------- --------------- Date ----------------------------••----) <br /> Septic Tank (Specify Requirements) -------Aoa-------/Z)`X-'yb-----f-a�"---nI-�-�--------------------------------- ----------------------------- <br /> Disposal Field (Specify Requirements) -------------- -------------------------------------------------------------------------------•----------- <br /> ----------------------------------------------------------------------------------------------------- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> �� r <br /> j SignedDlt —. r = - --------------------- Owner <br /> By ------------ --------------------------------------------------------------------------------- <br /> ----- Title ---- ----- ------ ----------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE --- ------------------ <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------- ------ -- --------------------- DATE <br /> ADDITIONALCOMMENTS ---------------------- - --------------------------- --------------- --------------------- ------------------------------- -------------- <br /> ------------- <br /> -------------------- -------------------------------------------------------------------------------------------------------------- ----------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- -- <br /> ------- - - -- ---------------------- <br /> Final Inspection by- ------------------ Date - <br /> ' SAN JOAQUIN LOCAL HEAL (STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />