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FOR OFFICE USE: <br /> TO Y h APPLICATION FOR SANITATION PERMIT <br /> �3—///s <br /> --------------- <br /> PerNo. --------------------- <br /> I (Complete in<Triplicafie) <br /> - -. 3 <br /> ---------=-- ------- <br /> .---- r--------------- _-_ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is Hereby made to` he Soh Jbdquin 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: <br /> 1 1 �I <br /> JOB ADDRESS/LOCATION -----` -_$#-- ------h--- �f��1�- ---.--- / G -:-------CENSUS TRACT -------------------------- <br /> 1 ! Phone -- _- -_ <br /> Owner's Name• -----l_I�-----:-- 'd--r-✓'-j--�-`-�----------------�;----------- •-------=--- ------------------�--------- --- <br /> Address I 4P74:- <br /> ------------------- ------------ city G-s ---------------------------------1 -------"------ <br /> Contractoris Name ---- <br /> I k `� License # .-g dr ✓� '1---- <br /> • } i � Phone <br /> Installation will serve: i Residence U Apartment House-[] Commercial:❑Trailer Cou y !❑ <br /> T Motel ❑ [?them =`-Y - <br /> i �� E <br /> Number of living units:__.-___;__ Nvmber of bedrooms -- -__Garbage Grinder -- -.-- Lot Size ------------ <br /> Water <br /> --_---_-__Water Supply: Public System nd name ----------------------------------------- ----------------------------------------------------•----- ---------Private <br /> �f I 1 <br /> p Character of soil to a depth ofi3 feet: Sand'❑ Silt❑ Clay [J44d\t❑ Sandy Loam ❑ Clay Loam ❑ It <br /> } Hardpan ❑ ""Ado"be= Fill IGlaferIf yes; ---------------- <br /> ialR <br /> -- <br /> (PI-ot plan,? showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: I f `3�� <br /> {No septic tank or seepage pit permitted if public sewer is available within 200�feet,},` <br /> i t / l 1 <br /> PACKAGE TREATMENT { ] SEPTIC TANK:i ] Size------ -"� X1�__�_____ Liquid ,Depth _--- <br /> I ? 00 <br /> �i`ti e ezf_ Material---------------------- No. Compartments <br />� 1 Capacity -�� --- ------- Type �J-- --� `- p! --�---�---=•- - OQ <br /> I I Distance to nearest: Well _----!� ----------------------Foundation -/0-----_--------_ Prop. Line --_- ..........__ <br /> 09 <br /> LEACHINGILINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ---------------- <br /> D' Bo <br /> --------_-_---B x --:--------- Tempe-Filter-Material Filter Material -----j------------- -----• •------ ----- <br /> i -_-- Foundation Property Line_ --------------------- <br /> SEEPAGE <br /> 1 <br /> - _ Distance to nearest: Well -------------------- -- --------------------- p tY ----- -=----------•----- <br /> SEEPAGE PIT [ ] Depth ---------------`--.- Diameter ---------------- Number Rock Filled Yes ❑; No <br /> j Water Table Depth -----'------------------------------------------Rock Size -------------------------------- ) E� <br /> i ! Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----'____-'-------- <br /> # i I. <br /> REPAIR/ADDITION1(Prey. Sanitation Permit# --------------_---------------_------------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----i-------------.------- € <br /> I <br /> Disposal Field j[Specify- Requirements)1 -------------- ----'---------------------------------- ---------------- �! <br /> ------------------' ---------- -------------------'----------------------------------------------------------------- --------------------------------------------------------------------- -I--------------- <br /> ---------------- _ = 4 <br /> "4-(Draw existing and required addition on reverse side) <br /> I hereby ce;'rtify that I have prepared this application and that the work will be done in accordance with Sari Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home ownei.or.licen- <br /> sed agents-signature-cer..tifies-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 orkm 's Compensation laws of California." ' <br /> Signed ------ 7----'--f a ------ Owner <br /> BY ----------------------------------------------- ---- ------ Title ---- <br /> (If other than owner). <br /> E i L FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --j --------------------------------------------------------------------------- DATE ----------------------- E-------------- <br /> BUILDINGPERMIT ISSUED ------'----------------------------------------------------------------------------------------------------DATE -------------------------- <br /> ADDITIONAL COMMENTS <br />' ------- <br /> ---------------------- <br /> ---------------------'---- --------- ---- ------=----------------------------------------------------------------------'------------------------------------------------------------------------- <br /> Y <br /> -------------------------------------------------------°_---.____-._______-_----.----------_-----__-__^<--(w--- ___.VIST'R <br /> �- _f�yn__ ______ <br /> �!v <br /> `-------------- - <br /> 1 Final Inspection by: -----------------------Y-- - --- ------ -----------------= �--='-'---`----=----- - Date ��` �� � ----------- <br /> SAN <br /> - -------SAN JOAQUIN LOCAL HEALTHICT <br /> t <br /> E. H. 9 1-'68 Rev. SM <br />