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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _cc�� <br /> ............................................. <br /> (Complete in Triplicate) Permit No. -7q---Jv.. <br /> ... This Permit Expires 1 Year From Date Issued Date Issued J_._-............. <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..._._._.1�,."� '7tsl......I.tip.�.._-cL?.[wst-A._-i'& '...L ..... ..........CENSUS TRACT -Z-V_`_..._.____.--- <br /> Owner's Name -.. --•-----._..C_FIZA .S---------------------------•-•_-•------------------------------ ---------------- .•-Phone <br /> Address ------------------------------------------301f 174----------------•-------------------------------•--• City -•-7 -•---------------•--------------------------------•---- <br /> Contractor's Name ................-------CM-0.'14f1........................_...... -- •--••----._.License# --•---•--:.............. Phone .............................. <br /> Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer Court 0 <br /> Motel ❑Other ---------------------- .......... .......... <br /> Number of living units ... Number of bedrooms ...3.....Garbage Grinder ....Y... Lot Size --------------_......__--_-..--........... <br /> Water Supply: Public System and name .............................................. .........----------------------------------------------------.Private ❑ <br /> Character of soil too depth of 3 feet: Sand'0 Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam ❑ <br /> Hardpan L7 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................................................ Liquid Depth .......................... <br /> Capacity .................... Type -----------------•-- Material_---------- ...._. 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 ............ Type Filter Material ....................Depth Filter Material __.--------------------------------------- <br /> Distance to nearest: Well -----------------------• Foundation __.__ .................. Property Line ........................ t/ <br /> SEEPAGE PIT [ ] Depth .................... Diameter ............. Number ............................ Rock Filled Yes ❑ No Q ; <br /> Water Table Depth ................................................Rock Size --•-•----•• -----_---_------- <br /> Distance to nearest: Well .........................................Foundation .................... Prop. Line ...................... ? <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------__.-,-.__-----) 7 <br /> If <br /> Septic Tank (Specify Requirements) G�L1..QF--- - - ........_...-...........................,... <br /> -- <br /> DisposalField {Specify Requirements) --•.......................•-----.........-•-•-•-•---••---•--••---•---•-••---•----••----•-••------••-- ---•-•------------•-------•---- <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 become subject to Workman's Compensation laws of California." <br /> Signed -- .-... -•----- .......................... Owner <br /> By)(. Title ....... -------- ---_------_-- -------------- ---•-----_----- <br /> (If other than owner) <br /> FOR DEPARTMENT YgE ONLY <br /> APPLICATION ACCEPTED BY............................................. -•-•----- - _ .--_.. DATE _./Y�-- 7'j_-..---__-------•- <br /> BUILDING PERMIT ISSUED--------•---•--•-......-----•••••---- ...............DATE ---•-----.----..•_._...................... <br /> ADDITIONALCOMMENTS ----•• •-----......•---•-...----••------.••--- ---------------••-----.---_-•---.-------------- <br /> -------------............................................ ......................... ...... -------------------------- <br /> n-__ � >._.._._ <br /> ............ <br /> Final Inspection by: -------••-••------------------ ........................................... Date:.�- ,�- _.... <br /> �4 <br /> SAN JOAQUIN LOCAL H DISTRICT <br /> E. H. 9 1268 Rev. 5M <br />