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FOR OFFICE USE: APPLICATION FOR"SANITATION PERMIT <br /> Permit No-. <br /> (Complete in Triplicate) <br /> ----------- --------- ---------------- <br /> --------- - V. Date Issued <br /> --------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per'mit to construct and install the work herein <br /> described. This application is made in compliance with County Ord.inance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOC CENSUS TRACT -------------- --__------- <br /> �/ Phone ------ <br /> Owner's Name IM-101Z7 _4 <br /> ADDRESS/LOCATION Y <br /> __J------------------------ <br /> Address ------------------------------------------ <br /> -Aln-Alff-sr--------------------- --- -------- city _Sr <br /> ----------License* -------------------------Phone -------------_----- --------- <br /> Contractor's Name ---------------- ----- <br /> Installation will serve- Residence 0 Apartment HouseR Commercial f-]Trailer Court :0 <br /> Motel EJ Other D-l"Pte --------------------- <br /> --- <br /> Number of living units:--- Number of bedrooms __�-------Garbage GrinderLot Size <br /> Water Supply. Public System and name -------eA-----------Private El <br /> Character of soil to a depth of 3 feet: Sand'El Silt 0 Clay [D Peat F Sandy Loam GayLoam 0 <br /> Hardpan 0 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 [ ] SEPTIC TANK'[ Size--,5- 4--SO--------------------------- Liquid Depth ---------- <br /> Capacity nZY00------ Type C47&d/?f'TA%ateriaI---------------------- No. Compartments ------ <br /> Distance to nearest: Well <br /> ----- ------------Foundation _—M----------- -Prop, Lind <br /> 2 ----------- <br /> LEACHING LINE No. of Lines ------Vn------------- Length of each line------ Total Length --- ,0_0----- <br /> n . I I <br /> 'D' Box ----- Type Filter Material Jj�p4A Deptl� Fitter- Material ---/f-------------------- <br /> 1 7 <br /> Distance to nearest, WeTI I.-MUf------- Foundation a5F'—__Z_0-- Property Line <br /> SEEPAGE PIT Depth _AJ�.......... Diameter ---4:33------ Number ---------147n- ----------- Rock Filled yes-.(R] No f3 <br /> Water Table Depth ---------------------------------------- -------Rock Size <br /> Distance to nearest: Well --------------- ...•Foundation .,)_C715__ Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------------- <br /> Septic Tank (Specify Requirements) ----- --------------------------------------------------------------------- -------- ------------------------ ---------------- ----------- <br /> Disposal Field (Specify Requirements) ---------------------7----------------- ----------I------------------ --------------------------------------------- --------------- <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents sig'n'ature certifies the following: <br /> "I certify that in the performance of the work for which this pefmiuiSrisiiiued, I shall not employ any person in such manner <br /> as to become subject to,Workman's Compensation laws of California." <br /> Signed -- ------------------------------------------------- ------------------------------------------- Owner <br /> By -------- - ---- - <br /> ---------------------------------------------- ----------------------- title ------------------- -- ---------------- -------------------------------- <br /> - __----------- <br /> [If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> r <br /> 1�w I ----------- DATE ---•l---- <br /> APPLICATION ACCEPTED Blii'�11. - --------r-------------: <br /> -------DATE - ---------------- <br /> BUILDINGPERMIT- ISSUED -------------- ------------ ------------ ----------- ----------------------- -------- <br /> r,I - -------I------------------------------- <br /> ADDIT10NAL COMMENTS----------------------i------------ ------------- -7------------------- -- -------------------------------------------- <br /> II ------------ <br /> -----------P 0_��5----------:!&r b. - -------------------- -------------------------------------- ------ <br /> --- -------- <br /> ie <br /> ------------------- ------ -- ---- ----- ---- <br /> ---------------------------------------------- <br /> �DTE --- <br /> DATE <br /> ---------------------------------- ------------------- -i4z-*M��------------------------------------------------ <br /> FinalInspection by: -------------------------------------------- -----------------------------Date ---- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />