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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- - S1 <br /> Permit No: ---7-�----- <br /> ` N (Complete in Triplicate) <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 <br /> No. 549 and existing Rules and Regulations. <br /> a / <br /> JOB ADDRESS/LOC4104 <br /> / 6" t 46 - ,/�� _-_CENSUS TRACT __-______ ___--_-__--.- -- - <br /> Owner's Name t Phone <br /> Address-------- ------ ---- - --------------------------------------------------------- City -------------------------------- --------------- ......................... <br /> Contractor's Name .---------- -- --------------- ------.License # ------- -------------- Phone -----------------------_-•-- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- 17.1 of living-units:______ _ Number of bedrooms --- Garbage Grinder ------------ Lot Size --------------------------------- ......... <br /> .............. <br /> Water Supply: Public System and name ----------- -----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ___________ If yes, type _____________________-____ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size------______•-_-----______________------------ Liquid Depth -_____-______--_.._.•-_- <br /> Capacity111-0v------.-- Typed /---- Material_I2IdPr4r4d --- No. Compartments -..................... <br /> i <br /> Distance to nearest: Well A10-49- _______________________Foundation __/®_--________-. Prop. Line -_,. °Q <br /> S'd___._______ <br /> LEACHING LINE [MI"INo. of Lines ------ ------------- Length of each line____.? -------------- Total Length .............. 00 <br /> 'D' BOX ------ Type Filter Material4��.Depth Filter Material ----A9•---X-3L_..._La.t. e.. <br /> Distance to nearest: Well ______ Foundation __4�_/_-_______ Property Line ........................ N <br /> SEEE' GE PIT [ ) Depth ___________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ . <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- 7 <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... -) <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> ------------------- Date ----------------------------------) d <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------- ----------------------------.-------------•--•----- ---- <br /> Disposal Field (Specify Requirements) .__-_..'_-__ ------- ------ <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 j ct t Works �Co�mpens;tton laws of California." <br /> Signed --- - ------------ -_----------------- Owner <br /> By ------ --------------------- ----------------------------------------------------------------------- Title -------------------------------------------- ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLWCATIOhL ACCEPTED_B. Y. - - -*- - ----- DATE 3� `,�� --_-------- <br /> BUILDING PERMIT, ISSUED ------------------------------ ---- ------ ----- - ---- ------------ ---- -DATE -_---- ----------------------------- <br />- ADDITIONAL COMMF,NTS-= ------ _u -, ; ----- ----------------------------------------------------- --------- -------------- -------------=--------- ------........... <br /> ------------------------------------------------------------------------------- ----------- ------ -- - ------------------------------------------------------- --------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> - ----- --- -- --------------- - - -- +--------------------------------- <br /> Final <br /> --- -------------- <br /> yam- - - - - ---- <br /> Final Inspection by: 6/ GX Date3 ---- <br /> SAN .JOAQUIN,.LOCAL HEALTH DISTRICT <br /> E.H. 9 1-'68 Rev. 5M <br />