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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. 27.4/ ......... <br /> . .. ........ ............... <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 No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION ...I-7-7 �.__.. ... �/ ? 1L ���: fir - __....-CENSUS TRACT .. <br /> Owner's Name ...... _.:'-F--�'�--. s�.�...................... -- . --Phone .................................... <br /> �7 ` <br /> Address / rj --.. t . ..._ £, ................... City �4....-.................................... <br /> cam, U <br /> Contractor's Name ��~�' ce0 st�t -� - License # �yp -.._ Phone .............................. <br /> r <br /> vw <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ---------- --- ----- --------- - <br /> Number of living units: . _ Number of bedrooms __.__Garbage Grinder .-.. -- Lot Size _. .G-'L-'�--*x:.e----- X <br /> Water Supply: Public System and name ------------------------------•-••- ------------------------ ------------------------------------------------Private V <br /> Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <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 [ ] SEPTIC TANK f x------ �. ....... liquid Depth .......... <br /> Capacity -t'--- P.P- -�.J TYPe ----------- J'••- Material._ S<� ...__. No. Compartments _c -................ <br /> / Distance to near st: Well ..........._57,1../,l.........Foundation ----- 0..._.--.-___ Prop. Line ..��............... <br /> LEACHING LINE ! No. of Lines _ .--..1. <br /> [ ] ___..._ Length of each line------�Q.._------------- Total Length .......... <br /> 'D' Box _J . _ Type Filter Material .._S ._..._Depth Filter Material .......................... <br /> Distance to nearest: Well ---- G ........ Foundation .._/;.. ........... Property Line ._...��__._.._.._...._. <br /> SEEPAGE PIT (,1 Depth - ..____ Diameter Number .-...------------------ Rock Filled Yes [ No [] <br /> Water Table Depth ---------------{-a...........................Rock Size . - ..?... ' P� <br /> Distance to nearest: Well ............../10V...._-._.__---__Foundation _��__...__....__ Prop. Line .S_..__..__._.._._ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ..................................) <br /> Septic Tank (Specify Requirements) ---------------------.-•-----•-•--------------•------•---------•------.•----•---------•---_------------- •----------- -------------- <br /> Disposal Field (Specify Requirements) ---- ----------------------------------•-•-•----•------------------------------------.-..--------------••--------------•---- - <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 San 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, 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 /> ,, y <br /> By . _ .. ._....................._....._ - '�: = `� "`�`.,a .. Title - - <br /> (If other than owner) V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ------------ ----------------------------•--------------•-------.....-- ..................... DATE ..... � .. 7.f.--•-----...... <br /> BUILDING PERMIT ISSUED ..------•. <br /> - . _ DATE ................................................•-.........-----••••. <br /> _..ADDITIONAL COMMENTS ..----•----•-•--•----------•-•----------:. <br /> ..-•--•---------- ----------------- -•-••--•-...._............----••------...._.._......._._....._---••-•--•-•..._............•---••--•---•••......._.....--•-•---- <br /> ................................... <br /> ........................... ------ ......................_..........-- --.......•-----..........-•••--••••----•------••-...........-----•.._._....•..... ..... •----------•-----.. <br /> .............................................. <br /> Final Inspection by: ................,- . ............._.....Date ... .......• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT DO <br /> r i i 7/a i <br /> ­n n_.. cu 7 /77 Z M <br />