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FOR OISM USES <br /> APPLICATION FOR SANITATION PERMIT <br /> -- .......................... <br /> -----''-----'....... �..$.�( <br /> - (Completein Triplicate) Permit No. .IOIL <br /> .................................................... Date Issued _z:!:-1M69 <br /> r This Permit Expires 1 Year From 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 No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCYI <br /> I N /G..B ._. !/.t - _ - _ r --.. .¢... -..._...... . -----.-....-CENSUS TRACT <br /> Owner's Name .... . . . .... / /��.-.J............. ----}-2 Phone - ................... <br /> Address ...... X1.7... .. .--5°sr=l�ssnl.--`sd '........ .. City .......... -............................................. <br /> r /�� <br /> Contractor's Nome ....._.. .-.. ... . . :� _GSIa<4..:.....__Lieense 9P ..f.g1.3-�-Y Phone ......................._.._. <br /> Installation will serve; Residence Apartm -------------------- <br /> House 0 Commercial❑Trailer Court ❑ <br /> r 1 <br /> Motel ❑Other . ..------.............................'- <br /> Number of living units:------ .... Number of bedrooms .7......Gorbage Grinder ...Y..... Lot Size .. ____ ... ... .......... <br /> Water Supply: Public Systerri and name ..........._......................-. .................._.._...-....-----.........._.--_-.........!...-Private Q -,� <br /> Character of soil to a depth of 3 feet: . .Sand.❑ Silt❑ Clay ❑ Peat❑ Sandy LoamClay Loam❑ <br /> Hardpan❑ Adobe 0 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 seepssge pit permitted If p14c sewer is available within 200 I�I� tjLN <br /> ,) <br /> PACKAGE..TREATMENT '( ] SEPTIC TANK Sire-Vee 4..4................ Liquid Depth .X......_____......-.-. O <br /> v s - 111 <br /> Capacity .-1. _ 44. :Type . Materlal0_ U0L—_.._. No. Compairm nts _"p .......... <br /> 1 - <br /> Distancce.to nbQFe . Well ...........adr.P.._-I...............Foundation . 1-0 ---.------ Prop Lin... �� . <br /> LEACHING LINE' [A_-*,Na.`Qf.,Lines ..I- .r; �__....... Length of each -----.��.._--_--._--__ Total length 4�R.-.._......... <br /> 'D' Box .. :j. pelFilter•MaMrial ..' ...Depth Filter Material --.--._--..... <br /> Distance to nearest: Well .. '�ti*S!4�......-� Forgdatlon .---1.0............-- Property Llne .... .......... <br /> 1 ..r ._ - <br /> SEEPAGE PIT [ ) Depth .._..... �.. Diameter ��"...L Number ---.---------_.�._....y.,,..�_.....�.. .Rock Filled) Yes Q No i❑ <br /> IV <br /> Water Table Dearth .............Rock Size _`l,xTf4.....----.-. •r <br /> Distance to neareIt:-Well .................__....... .........Foundation,............... Prop.11in ._.. ........... <br /> REPAIR/ADDITION•(Priv. Sanitation PellttP ----,-...-•----...._.........-. <br /> SepticTank (Specify Requirements) ................--....................._...................._................^........----------. ................... <br /> Disposal Field (Specify Requirements) ------'..................;.....----....------------....._..........................-"......-_.........,......__........... <br /> s <br /> ..._..................................-----------...3.-........_................................. ...'.........................................................---- ----'C---------------------- 4" <br /> (Draw existing and required addition on reverse side) r 0 C <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance Iwiib�an Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any pen;en in such manner <br /> as to beta svblect to Workman's Compensation laws of California." <br /> Signed .... _..._.... . .. .. .. ............--- Owner <br /> . .. _ _ J[� <br /> By ..... -..... "__..."_-.. ..... lit 1A./ IL!!: i............................. :... <br /> .................... .. <br /> (If other than owner) <br /> It FOR DEPARTMENT.•'USE ONLY <br /> APPLICATION ACCEPTED BY _.----_..- . DATE ... <br /> BUILDING PERMIT ISSUED ---- I <br /> _.....DATEADDITIONAL COMMENTS ... ----------- ----------------------- -� - _..............-"-•-'•.._ .... ----------------- --- _•_•_------........ <br /> ............ ......... -- -..-•----------------_.........-'- .- . .. <br /> Final Ins octan ..Dote ..-. ..c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />