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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION P' 11T <br /> ------------ --- --- --------- ------ <br /> (Complete in Triplicate) Permit No. <br /> -----------------------------------­------------- ------ <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/LOCATION . _.y' <br /> ��T--1�-,J------ Q����'_/�-/�--��1�`----� .--•_....__..,CENSUS TRACT -------------------------- <br /> Owner's Name --- - ----------------- •-- -- -- ----Phone -';------------------ --------------- <br /> ----- - <br /> e � , <br /> Address --------------------- City(, ' �' <br /> Contractor's Name ___ '/-G-', '!� ._- ./ P_—; `.._____ _----------___--------License Phony __I 1 <br /> t . <br /> Installation will serve: Residence H use'❑ Commercial ❑Trailer Court i❑ <br /> Motel <br /> el ❑Other' ------ ------------------------ <br /> Number of living units:... ..... Number of bedrooms I rbage Grindwv _ Lot Size ��G���� •�_-_:,.___ <br /> Water Supply: Public System and name ----------------------• f---•--- -------------------------------•--• ---------------------------------_.Private, <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ _ Cla ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑' Adobe ❑ II 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____________________________-_---I Liquid Depth ___. --------------------- <br /> T - <br /> Capacity -------------- ---- Type -------------------- Material r . No. Compartments ...................... <br /> Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line ________----_---______ <br /> LEACHING LINE [ ] No. of Lines -------- --------------- Length of each line___________________________ Total Length ----------- ................ <br /> 'D' Box ------------ Tye Filter Material ____________________Depth Filter Material __-__.______.___________._____.______-______ <br /> Distance to nearest: Well ________________________ Foundation .----------------------- Property Line _______-_-.--_____-_-___ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ..-------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------------•--- <br /> Distance to nearest: Well ---------------------------------'_------Foundation -------------------- Prop. Line ____--__-_.-----_-.--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date _______-_____.____________-_-_____) <br /> Septic Tank (Specify Requirements) = - -- <br /> �j r y <br /> Disposal Field Specify Requirements) __ '�l_ ____________ i __________ Y _ __.__. �` _____----- ____---. x,, 13 --�- , <br /> --------- ------- <br /> �� >� : <br /> - ----------------------------------------------------------=---r------ ---- <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 /> "1 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 I s of California." <br /> Signed ---- --------------------------- --- ----------------- - --- --lq-VDEPJ� <br /> ----------------•--- Owner <br /> By ----------------- ----------------- d Title �ZG "- <br /> (If other t owner) ENT USE,,ONLY / <br /> APPLICATION ACCEPTED BY -- ---- , DATE 1--� - -------------- <br /> BUILDING PERMIT ISSUED ----- ✓C. ---------------------------------- ---DATE -------- ------ - ------------------- <br /> ------- ---------- ------- ------------- -- <br /> ADDITIONAL COMME ----- ----- _ ------------------------------------------------- <br /> ----- <br /> ----------------------------- ---------------- <br /> ------------------- <br /> t� 7� ------ - - -- -- ---- -------- 'r----- . <br /> � --�- -�-- - Q--(�'�+------------�---------�-- �m-Aul--�-----�' � rte' <br /> 1(/ U <br /> ----------------------------------- ------ -- --- - - ----------- ----------------------------------------- ----:--------------------------------- -------------------- -------------- <br /> Final Inspection by: ----- - - ---------------------------------•---- ---------------------------------.-Date ------- <br /> L�) <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />