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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----- ----------------------------- ----- <br /> {Complete in Triplicate} Permit No. <br /> _7_757:7,//--- <br /> _ __---_-------------------__------------- <br /> This Permit Expires 1 Year From Date issuedDate issued _9* <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe d r st II ' herein <br /> described. This application is made in compliance with <br /> County Ordinance No. 549 and exist es and I�egu !tkons: <br /> JOB ADDRESS/LOC ONI� / -- -- �'c*.r. ✓ -'rarsr- `r'----- CENSUS TRACT <br /> Owner's Name --- ------- --- - ---- - ---------------- -----•--------------------- ----Phone -------------------------- -------- <br /> Address --------- ---- j ------------- City - ----------------------------------- <br /> Contractor's Name ------ -.License # Phone <br /> Installation will serve: Residence [ Apartment House,] Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other -------_---/------------- ------------------ <br /> Number of living units:---I__.._ Number of bedrooms -_ _Garbage Grinder ------------ Lot Size ----.------------.-------------------------- <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 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 ] Size----------------------------------------- ----- Liquid Depth ---------------------.-_-- <br /> CapacitY -------------------- Type -------------------- Material----------- No. Compartments ------•--------------- <br /> Distance to nearest: Well ------------------------------------Foundation --------- ------------ Prop. Line ___------------------ <br /> LEACHING LINE No. of Lines ----------I------------ Length of each line-------- --------- Total Length ----4L0---------- ------ <br /> -- Type Filter Material ____S__�______Depth Filter Material -_-_�y_--_-.________ ___________________ <br /> 'D' Box -------- <br /> f <br /> Distance to nearest: Well ------I-PO___-_____ Foundation _.____�_C!-_____.__.__ Property Line. _________________ <br /> SEEPAGE PIT [�.]� Depth ...... Diameter --------- <br /> ______`3-3-"Number ----------f----------------- Rock Filled Yes No i❑ <br /> Water Table Depth ------- --------=-------------------------------Rock Size ___3 v'f ------------ <br /> Distance to nearest: Well ------------br"__'-----------------Foundation ------- ......... Prop. Line ___.S._____..-_.-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------.---------------.-_-----) <br /> Septic Tank (Specify Requirements) -------------------- --------------------------------------------------------------_--------------------------- <br /> DisposalField {Specify Requirements) ----------------.-------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- --------ri--- - - ------------ ------ ---------------- <br /> ---------------- <br /> c_,,,�-- .-�--.�. -----f-- ------33----YDS----- * <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 /> --------------------- <br /> ----------------------------------------------------- <br /> �—� Title _-._ .__._ . __.�__--.( +i------------------------------------------- <br /> (If other than owner) <br /> 6 <br /> FOR DEP itTMENT USE ONLY _f <br /> APPLICATION ACCEPTED BY ---- - ---------- ---------------------- ------------------------------------- DATE _ d_.Q -------------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> - --------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- -------------- <br /> ----------- --------------- - ----------- --- -- - ------- ------ ------- _ <br /> Final Inspection by - -- ---- Dat D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />