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FOR OFFICE USE: <br /> APPLICAT�QN_-FOR SANITATION PERMIT <br /> Permit No- <br /> (Complete-in Triplicate) <br /> ---------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> -------- --- --------------------- <br /> _-------_--__---- 69-��_V <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 /> f .r <br /> JOB ADDRESS/LOCATION ----CENSUS TRACT --------------- ---------- t <br /> Owner's Name ------ aim(_3i5 Phone <br /> �l <br /> Address -- -------------- ` ----- ---6�- --- --- "�-- ----- ------------ City ----*_ P ----- r <br /> Contractor's Name ------ ------- -��-------- ---------License # Phone <br /> Installation will serve: Residence X Apartment House-E] Commercial:❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> 14 <br /> Number of living units:----- ___. Number of bedrooms ----3----Garbage Grinder _/Vd___ Lot Size ------:�7_ -_----_-_-_ � <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan Adobe-W Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> __-___-_----___--_-_(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse sidwjj <br /> NEW INSTALLATION: (No septic'tank or seepage pit permitted if public sewer is available within 200 feet,) I <br /> PACKAGE TREATMENT [ ] ' SEPTIC TANK: Size------ -__ a______/Y___ ___ _______ Liquid Depth ---�`----_-__ <br /> --------- - <br /> Capacity l _aQ- Type ___________ _ QMaterlal_CQ—,,c `___ No. Compartments --_---�.__...... <br /> Distance to nearest: Well -.----S7a! _O.__.._.Foundation ------/0-/ Prop. Line ---- <br /> LEACHING <br /> --LEACHING LINE 6Q No. of Lines ----------- 2------- Length of each line---------- S ------- Total Length ______.IQ /-.----_- <br /> 'D' -Box _1151.... Type Filter Material _----- -__--_Depth Filter Material ----------------- Y__ --------------- <br /> Dist ance <br /> ______________Distance to nearest: Well ----- Foundation ..... ---------- Property Line -----`._........... <br /> SEEPAGE PIT [ Depth __-/p1_---_______- Diameter $I'Okl�- Number -----------:� --�-------- Rock Filled Yes Z No i❑ v, <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- fi <br /> � <br /> �---- r� -------Foundation A50 ----- Prop. Line ---------- ---- <br /> Distance to nearest: Wel! --�_. c <br /> / ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _-----_-_--_-____----.-_---_-__-__) ' <br /> 0 <br /> SepticTank (Specify Requirements) ---- ---------- --------------------------------------------------------------•---------------------------,--------- --------------- -- {t� <br /> Disposal Field (Specify Requirements) ----------------------------------- --------------------------------------------------- ---------------- i <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 becom"bje'.ctt4a Workman's Compensation laws of California." <br /> Signedc m?-sa-=J ���, Owner <br /> BY �1�2 r u`,"r 5 _. .- r-- ----------------------------------- Title . - `' ---------------- ----------------------- <br /> -- <br /> - <br /> (If other than_.dwnr) <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY -----� -- -- ------------- DATE -- --- -- - --------------------- <br /> ---------------- <br /> BUILDING PERMIT ISSUED '--------- ----------------------------------------------------------------------DATE ---------------------------------.--------. <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------------------.------- ------ ) <br /> -------------------------------------- -- __ <br /> - -------------------- ------------------------------------------------------------------------------------------------------- --------- ------------------- <br /> -------------------------------------- -------------------- ------------------------------------------------------- ------ <br /> -- - - ------ <br /> Final Inspection by: ----_ -- -_._ __. <br /> Dated --- <br /> 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> i E. H. 9 1-'68 Rev. 5M , <br />