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FOR OFFIC .US <br /> , APPLICATION FOR SANITATION PERMIT " .� <br /> -------------- - <br /> --------------- - =#"'07----------- <br /> (Complete in Triplicate) Permit <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 Nc6, <br /> 5549,pand existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . --fT k ---S4--- ,-o--------0--?-,- r!t_ �7- _j_.-CENSUS TRACT --------- .---------- <br /> Owner's Name / .f -y-- - � --------------- Phone <br /> Address .- G"� x -------s--� -5,f?�� I--------------------- City =.= 1 G? <br /> Name -------- ._4 -_ ---/ icense # � Phone .----------- <br /> Contractor's <br /> Installation will serve: ;Residence p artment House-❑ Commercial : Trailer Court i❑ <br /> I Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------- ---------------------- -- <br /> Number of living units:.../_.._- Nu"ml3er of.bedrooms _._...Garbage Grinderl�l� � <br /> o- Lot Size -------------------------------------------- <br /> ----------- <br /> Water Supply: Public System ands n,anle --------------------------------------------------------------------------------------------------------------Private,Lh' <br /> Character of soil to a depth of 3 fee # Sand-V Silt[] Clay ❑ Peat --"Sandy Loam ❑ Clay Loam ❑ s <br /> .H'ardpan E] Adobe [:] Fill Material _ -__ If yes,type ---------------------------- <br /> (Plot pian, showing size of lot, focation of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic'tarik or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------- <br /> 0:1------------------. Liquid Depth ----- ---------- --------- <br /> Capacity-;------`--------- -- TYPe --------->---------- Material--------------- ------ No. Compartments -----____-----•- <br /> Di's'tance o .nearest: Well ---------i-----------------I--------Foundatia'n ----..-----------_-_-- Prop. Line -=-----•--•----------- 0 <br /> LEACHING LINE { ] hfo °'of Lines ------------------------ Length of each line---------------------- Total Length ,__.--.-_--.-..--_._....._-- <br /> r'D' Box .. ....�`.. Type Filter Material --------------------DeptK Filter M�teriai ------------------------- <br /> ---.- ------------------ <br /> }� <br /> Distance to' nearest: Well _._.-_�_�---�--�_-_- Foundation`_________________._. Property Line <br /> _ _ 1. <br /> SEEPAGE T eof 1 Depth ----r-�- ----- Diameter, I---------------- Number -----------------------�_.__.Rock,Filled Yes '❑ No �] <br /> , x; .. <br /> Water Tabie Depth # • �"� - Rock'Size -__; ---------- - . <br /> d Distance to nearest: Well ___________________ _______________Foundation -_-__-----.._...- Prop. Line __..-__..-.__.-..._--- <br /> REPAIR/ECDDITION(Prev. Sanitation Permit# -------.-' `---------------------- Date ------------- <br /> Septic,Tahk (Specify Requirements) ' --------- -- ---k ----------------------------- - q <br /> Disposa! 'Field (Specify Requirements) - -tp--- -- ----- 7-------- - -----b'-'- -------------------------- <br /> ---" <br /> -v_ '-------- <br /> r s �. <br /> ------- ---� - --- ------------------ <br /> --------------- <br /> f (Draw existing and required adds ion on reverse side) ,( <br /> - s <br /> iro� --_._..-_. �. . <br /> I hereby`certi4 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 agerts 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 /> y <br /> as to become subject to Workman's Compensation laws of California." <br /> A <br /> Signed --------- Owner ^�-- <br /> - --------------------------------------------- <br /> --- <br /> (If o her than o nerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t .�Q ---------------- ----------------- DATE _J2-57 -------------- <br /> BUILIDING-PERMIT ISSUED ------ ------------------ ---- - -- - _ ----- <br /> _--------------DATE -._�. _ <br /> ADDITIONAL COMMENTS -- ---- ------------------=------- - - -= =----4---•------`--�---- `4.�.[...��,}�-------- <br /> -------------------------------- ------ - ---- ----- -------- <br /> .................................. ... . --------------- <br /> ---- <br /> ...A..__.._. <br /> --- ------------------ - _--- - ___ _..._____-___..--........_.-.__._-._____.______-_.--___.__-_--- <br /> Final lnspec ----- --------------------------- --Date { ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />