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-OR OFFICE 'PSE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - --------- <br /> Permit No: O_ �3 <br /> (Complete in Triplicate) <br /> ---------------- <br /> ---------------- This Permit Expires 1 Year From Date Issued Date Issued A ._ _ _____. <br /> Application is hereby made to the Son 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,.--------------- 1'" <br /> -- Li G✓ r �sy�-- ------------------ ---- ------CENSUS TRACT --------`----------------- <br /> ---- - - - -------------- ------ <br /> Owner's Name _D-L _�.E°1� ":0 f Jr�_V/9-1sr Qf _p-------------------Phone -------------------------------•---- <br /> tAddress 9� ---------J _aa,. 11V---------------------------------------- City _/i..nYhrw ---------------------------------------------------- <br /> �' 1 <br /> Contractor's Name ��. = 2 ��� --------------------- License # y le Phone 3" <br /> Installation will serve: Residence M Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ---------------------------------- -------- <br /> Number of living units;------ _---- Number of bedrooms __3------Garba `e Grinder ------------ Lot Size -------------------------- ------ . <br /> Water Supply. Public System and name -------------44 _� Private <br /> ' `- ❑ <br /> Character of soil to a depth of 3 feet: Sand'[d 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'[ Size---� - 1li.X--- ----- Liquid Depth ----��-------,----- <br /> I- d------------ `►7 <br /> Capacity _-/ U- ---- Type --�-d-&X&aterial No. Compartments -- ------------ <br /> Distance to nearest: Well -----yS ------------------Foundation __f �. --------- Prop. Line - -------- <br /> `� � <br /> LEACHING LINE [ ] No. of lines —3---------------- Length of each line----2-41--------------- Total Lenge _eVd---.----.-- <br /> D' Box -------_- -- Type Filter Material � --Depth Filter Material _ R-----------------•----.-----------• <br /> Distance to nearest: Well -------tO-___--.--- Foundation -._lll------------- Property Line �-.-----•-.----- <br /> SEEPAGE PIT [ ] Depth ------------- Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth - <br /> --------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------'------------- -----) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------••- •---------- -------------- ---•-----------------------•---- <br /> Disposal Field (Specify Requirements) -'----_-_--- - ------- ------------------------------------- <br /> t ----------------------------- ------------------=---------------------------------------- ------------------ <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 /> i as to become subject to Worknjgnvs Compensation laws of California." <br /> I. Signed _.. ---------- Owner <br /> BY -'--- -- - <br /> Title -'-- -------------- ----'----'----' '-------------' ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----RL--4$9S?V-------------------------------------------------------------------. DATE .../A--/;K--7q--------- <br /> BUILDINGPERMIT ISSUED -------------------------------------- `-RAO----------------------------------------------------DATE ------- ----------------------------------- <br /> ADDITIONAL COMMENTS --------------------------- ------------------------ ----------'---------------- <br /> --------------------------------------------------------------------------- <br /> ------------- ------------------------------ -------------------------------------------------------------------------- <br /> --------------------------------- <br /> Final Inspection by: __= _ Date ---- <br /> Final ----- -- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t E. H. 9 1-'68 Rev. 5M <br />