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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. �-� d <br /> (Complete in Triplicate) "'"""" <br /> This Permit Expires i Year From Date Issued Date issued <br /> f <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 wit County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....7f_..... �? ....�............................CENSUS TRACT ..5.`�.................. <br /> Owner's Name . . _ .. �---:�.. X � .... Phone , <br /> Address �. ...h: . :. ................. City ........................ i..--....... .. .. .. ........-• I <br /> Contractor's Name ._.: ��"' __S" `"` icense# :' �: ;''"'"'Phone.`::`. ::. ... <br /> i , <br /> Installation will serve: Reside epartment Mouse❑ Commercial ❑Trailer Court: ] ' <br /> Motel Other f <br /> Number of living 'units:....-_�._.:.Nuniber of.,bedrooms __._:Y Garbage Grinder.__ _.. . . ..LotSize.,! ... ........ � <br /> : . • ` N <br /> Wafter Supply: Public System and name ------------------------------------._ _----...__-.. Private. <br /> Q'! <br /> r ---- . - <br /> Character of soil to a depth of 3 feet Sand❑ Silt❑ Clay ❑ ` Peat❑ Sandy Loam Clay Loam ❑ <br /> :r �-� , ... <br /> - i-latdpon ❑ Adobe ❑ Fill Material _ .. If yes, type <br /> (Plot plan, showing size of"lot, location,..of,.systema.in relation ao.,wells;.buildings,.etc. must_.be,..placed•.,on.'reverse. side.) <br /> NEW INSTALLATION: (No septic tank or seep sge:pit,perrriitted if public sewer1s available within 200 feet,) <br /> PACKAGE TREATMENT. [ ] SEPTIC TANK Size........'-- ------------------ -------------- Liquid Depth . .. .... <br /> Capacity Type .............. Material______________ No. Compartments _......... <br /> Distance to nearest: Well ....... .... ..... . . Foundation Prop. Line ............•" <br /> LEACHING LINE [ ] No. of Lines -----------------------_ Length of each tine-__ --'_ _.----- Total Length;__-- ............... <br /> D' Sox -- ' = Type Filter Material - -..- ------Depth''Filter Mpterial` ' ; <br /> _ - <br /> Distance to nearest: Well _ Foundation :s Property9 Line a_.._ <br /> t., <br /> SEEPAGE PIT <br /> [ Depth i--------------- Diameter ____-•__•.-::_ Number . Rock•Filled,.,,.Yet []+ No Q <br /> i Water Tabs-Depth: <br /> ....................... .. '.Rock Size ------- - ---------------------- <br /> to <br /> ----------- „... _ . <br /> ;. Distance to nearest Well Foundation =' Prop Line <br /> r ;:. <br /> REPAIR/ADDITION IPrev. Sanitation:Permit -__"__________------------ Date ........ ...........__.........} ` <br /> !Septic Tank (Specify Requirements) ........ ............................ ..................... <br /> . . <br /> posal Field (Specify <br /> Requirements) <br /> i. <br /> , <br /> __ __" --.._-_._._."-_.___ 0 . ...................................... ..................... <br /> a <br /> / :• ---- - --------- •----.. ..........:.. --- <br /> (Draw existing and required addition on reverse sjde)" <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 haws; and Ru�es'bind Regulations of the'Sari 'Joaquin''Lotal Health Dlitrict.Nom*,dwner,ee Been- <br /> sed agents signature,certifies the following: <br /> "i certify that in the perforr'nance of the work for which this perm€t is iss�ed,'1 shall not employ any person in"such manner <br /> as'to become stibiect to WorkrKan's Com;pensatlon laws'of Califorriia." <br /> Signed ---------:. ... ::.__.+. . , y = Owner �,... .. .:..,, <br /> ;_ <br /> , <br /> :.... = <br /> tle _ <br /> (If other than ,owner} <br /> 3 f.- <br /> f' FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED 8Y s = -: DATE J. .7". ....:..... <br /> BUILDING PERMIT ISSUED ::__:_: ------ _.: .--••- _:: : .............. <br /> ADDITIONAL COMMENT5 . .............:......... = .. .. --- .. .......---..1 <br /> .. <br /> ... <br /> ...1 ... .....r. .............- - .... •I.•,' ....... . '.q.... ............,, .f..............i..,_,-� ;. <br /> .................... ... ....s. _ - :I. i.... ....y............. .. .. ....._..,... ..,.p.......{, •,t.y •1 <br /> _---_•........................ <br /> .. ......--------- ---­ ­ ...:`. .:� __ - _._ .. .. .. .» ... .. 9 ..~1` .`. .•.j .. .x <br /> Final Inspection by: ..' . Date a.�,..4 �.' • I <br /> a SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> r L 13 24 i_ ,&a a_., cu 7/72 3.M <br />