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FOR OFFICE USE: <br /> APPLICATION FOR' SANITATION PERMIT <br /> ""- "-� _ Permit No: _4�"_7�� <br /> (Complete in Triplicate) <br /> ___________________------ ------------ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby madetothe San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance,with'Cou ty Ordinance No. 149 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <------------CENSUS TRACT -------------------------- <br /> Owner s <br /> -------- ------ <br /> Owner's Name ---- - -�. -f s - - ----- - <br /> Address <br /> 134 aik--- -- --------- <br /> -----. City --- ----- - -- ------------------!---/ ------------------ <br /> Contractor's Name _ _____ ____ _ ___ -------- ____ _. .__--------License # o2�4FL�_�'_ Phone <br /> Installation will serve: Residence)<Apartment House❑ Commercial :❑Trailer Court ❑ <br /> a � <br /> Motel ❑Other --- ----- -----------•---------------------- ` <br /> Number of living units:.--- Number of kedrooms _,,-7 <br /> -----Garbage Grinder ___._..._...'.Lot Size 4a-Z..1P?.15------ <br /> Water <br /> _._Water Supply: Public System and name Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'0 Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam:❑ <br /> t <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 seepage pit permitted if public sewer is-available within 200 feet,) \ <br /> PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --__-------.__------------ <br /> Capaciiy --------------------- Type ---------E __ Material--------------------7, No._Compartments --------------- <br /> Distance <br /> "-----------Distance to nearest: Well ------------------------_-___-__---Foundation ---------------------- Prop. Line -_-.--_..._..:......_. 6�,y <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -------------------- -------- <br /> 'D' <br /> --.-_.---_-_.-.._-.---..._- <br /> 'D' Box ------- Type Filter Material ---_---__--_-__--_Depth Filter Material -----------------"_---.----------........._. <br /> Distance to nearest: Well ------------------------ Foundation --------------------------IrProperty Line. _--__-. .......... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------'_-------,r'-.-_ Rock Filled Yes ❑ No I❑ <br /> Water Table Depth --------------------Rock Size -------------------------------- i <br /> Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line ---------.-------__--• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---!__...---------------I--------- ----- Date ----L-.__--__..__---_.._-_-_-).,..-.�.� <br /> Septic Tank (Specify Requirements) - ----------------------- ---- ---- <br /> ------------- ----- <br /> - - - ' <br /> ------- ------ - <br /> Disposal Field (Specify Requirements) - - - ----------- - <br /> - -- --- -- - ------------------------------ <br /> - - ---------- ------ <br /> (Draw existing o d red, fired dition on,re'verse side) , <br /> 1 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'Son Joaquin SLocal Health-District. Home owner or licen- <br /> sed agents signature certifies the following: l I <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." ., t <br /> Sigd �- , -- - --------------- ----- - -�------�-.,_.- ----- � - Owner i <br /> BY F.. - -- - -- ---------------------- 1 Title c <br /> ------ - - -- -------- <br /> (If other than owner) <br /> 'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ~'�� <br /> .�'---. DATE ------J 7--- -&------------- <br /> BUILDING PERMIT ISSUED,_ _ _ _ _ _____ ___ y - ' I._._ ._DATE _..____._ <br /> a ------------------------------- <br /> ADDITIONAL COMMENTS --- ��--- -fir- � = ,iiY " !' ' ' ------ <br /> -T@te�. <br /> /. _ <br /> _ y__ --_---_--O_ _ _---- - - ---------- - '_ _ _ _ __ <br /> ___---___ �r7 /% <br /> ________________________________ _ --- ----- _ _______-_ _--- -_ .._-__-----_-__--___-__-_--_-_--.___-__--.---__-.--------_--___----__--__---_._♦_ .._____ -__-_--.--___..-___-_- F <br /> Final Inspection b <br /> p Y -----------` - ------`-------------------------------------------------Date ---- : ' x= <br /> N JOAQUIN LOCAL e;HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />