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FOR OFFICE -USE: APPLICATION FOR SANITATION PERMIT <br /> ----- ---- ---------------------------------------- -- - Permit No. <br /> Z <br /> -- - _ (Complete in Triplicate} - € <br /> ----- -- ----- - ------------------ cr+'/ f- �.�f <br /> • Date Issued <br /> ------ „ This Permit Expires 1 Year From Date Issued <br /> ----------------------------------------- <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 /> e r, c =----CENSUS TRACT --------------•-----•---- <br /> JOB ApDRESS/LOCATI,O:N -- ---------------------- - - <br /> = <br /> ,� i1d�5�P k_—,--- .�Xw------------------------------------------------------------------- Phone ... <br /> Owner's Name -, <br /> Address ----- --- ------- ' ��t � i � , �----------------- ------------ City -----��f� � _f-_ L./-* �----------- ------------ <br /> I T# ---- Phone _. __ �t T--? ._ <br /> Contractor's-Name _.__ __._ Go............... '- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court F1 <br /> Motel ❑Other --------- ----------------------------------- i -0^ ! <br /> Number of living units:_.I___---- Number of bedrgoms ___M____Garbage Grinder __+17-- __ Lot Size -_7 _)(---/-� ll----------- <br /> Water Supply: Public System and name -X .&----um ----�,.------------------------------------------------- -Private ❑ <br /> Character of sail to a depth of 3 feet: Sand'Q Silt[❑ Cl <br /> dy .❑ Peat ❑ Sandy­Loam ❑ Clay Loam ) <br /> ws i <br /> Hardpan ❑ Adobe ❑ 'Fill Material ----------- If yes;type "---_______--------- --- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, et»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_�S' �-------------------------:-.------------ Liquid Depth--------------__-------_-,----- v ktk <br /> Capacity -------------------- Type ------------------ Material---------------------- .No. Compartment's <br /> Q <br /> l <br /> �� -------- <br /> Distancet <br /> to nearest: Welt ___.___'__ _____________ _______�_,oundation - _,_t______---__.___ Prop. Line _ ____LEACHING LINE [ ] No. of Lines ________ _______________ Length of each line___f; -------_;____ Total Length ________..__.____ 1 <br /> 'D' Box __X------ Type Filter Material RoCk-----Depth\Filter Material ___-/_Z_ ____--_' - <br /> Distance to near st: Well _.---------- TM _ Foundation--- Property Line_,------------------------ <br /> SEEPAGE PIT [ ] Depth Diameter --- Number ------------------- Rock Filled Yes,r No C) <br /> Water Table Depth ------------------ ----------------- =--.Rock Size -------------------------------- X. <br /> Distance to:-nearest: Well ------------------------------ <br /> ---r---..Foundation -1-0----------- Prop. Line - -C?-_____.•------ <br /> -y <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______.._-___-- - --- <br /> ------------ -- -�''-,Date ---------- <br /> ,_---------- <br /> -----_-_--} <br /> SepticTank (Specify Requirements),-------- --------- ---------------------------------------------------------------------- --------- -- - ----------------------------- <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------------------ - -- ----------------------- -------------- <br /> ., m, .' <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-- , f <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 j <br /> as to become subject to Workman's Compensation laws of California." <br /> i <br /> Si ned <br /> g --------------------------- <br /> By Title ------ ---------------- <br /> k ----- -- ------------------------ ---------- ------ <br /> (If other tha ner) <br /> FOR DEPARTMENT-USE-ONLY-- -�-- --�* <br /> APPLICATION ACCEPTED BY -- ---------------------- DATE -- 4`^•- 7= 7 z <br /> 1 BUILDING PERMIT ISSUED ---------- '_ ` -----------------DATE __.---------------------------------------- <br /> ---------------- <br /> _-------- �r <br />( ADDITIONAL COMMENTS ----------------------- ---------------------- <br /> -------------------------- ------------------------------------------------------ ------------------- <br /> r - --------------------------------------------------------------------------------------, <br /> -- -- <br /> ---------------------------------------- ------ �- ------------------- <br /> 4 Final Inspection by= --------- ------ - --- -- ---- ------------ ---- ----------._.Date <br /> ��{r�- `- <br /> SAN J, A0 N LOCAL HEALTH DISTRICT <br /> 4 E. H. 9 1-'68 Rev. 5M •s: <br />