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V--- 'iOR OFFICE USE: <br /> APPLICATION FOR SANI'T'ATION PERMIT <br /> (Complete in Triplicate) Permit No. ....`�C-71?............ <br /> This Permit Expires 1 Year From Date issued 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 w' h Co y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..__. '` <br /> CENSUS TRACT <br /> . <br /> Owner's Name .._.. " .......... Phone <br /> •••..............:..... <br /> Address --- <br /> --------------- <br /> ................... City ....-................_.. <br /> Contractor's Name __________ ___ _ <br /> __.... ••••..................•-..License i0 tj.�-_1K- Phone i, � ....._ <br /> Installation will serve: Residence❑Apartme House 0 Commercial❑Trailer Court 0 <br /> Motel ❑Other ...... ...................................... <br /> Number of living units------{__.- Number of bedrooms .._...15.Z*.Garbage Grinder .._._. ..... Lot Size ...1 ...__.. :.._._ <br /> Water Supply: Public System and name -•.......................•-•..-...__...........------....-•-•----•--=------- ........ - v <br /> .._.Pri ate <br /> Character of soil to a depth of 3 feet: Sand O Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam b <br /> Hardpan d Adobe 0 Fill Material ............If yes,type............... ............ <br /> Ir <br /> }Plot plan, showing size of lot, location of system In relation tarwells, 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 f ] SEPTIC TANK; ] Size..._ -_ .. j--• -•1 --------- Liquid Depth -- ---------------•-•- <br /> Capacity �_.oL G'_-_-- Type .. ----------- Material... No. Compartments __-�....._...- <br /> Distance to nearest: Well __ _,.Foundation ___- __.......... Prop. Line <br /> LEACHING LINE [ ] No. of Lin ies _/-.._..__..-•---••_-- Length of.each line.. "f t :::::..:..... Total Length -- .................. <br /> 'D' Box Type Filter Material ...._/ . __._-Depth Filter, Material _�/ .� <br /> Distance nearest; Well ........ F nation ............:........... Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ._.__�.............. Diameter ................ Number ............................. Rock Filled , Yes ❑ No 0 <br /> ' <br /> Water Table Depth .......••-------------• ........................ Size.-•-•-i <br /> ....... ................... <br /> Distance to nearest: Well ..........____ <br /> •.........................Founds#ion ..._._...----------- Prop. Line ...................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit 54s _ Date ............................... <br /> Septic Tank {Specify Requirements) <br /> l -- -- -- -------------- <br /> -- -- ---- -......-- -----------••-� <br /> �-. . . ..... <br /> Disposal Field {Spey Requirents} <br /> " 'O10, <br /> -------------­- 7 ...... ...... ••• •.--.............--•----..•--•----•..__.._.._....... <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 Soot 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 /> V <br /> By ------ Title - ............ <br /> (i 'o -I -- --------- <br /> th r t an r} <br /> i <br /> F0Jt DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... ---- - ----------------------------- <br /> -- --------------------------------------- -- ---_---------,.: DATE <br /> BUILDING PERMIT ISSUED ----...--- --------------------------------------- <br /> •--------------------------------•------ <br /> ADDfT10NAL COMMENTS ` •...................•-------------•--- --"---------._ ................... - -------- ------------------------•.__.._...:_..... <br /> -------------•----------------------- -• • -•... -------•--_-- ----•-•-------• ---------------------------------- --•- -- ---------------_- ----------------_-• -•----- -------- <br /> ----"--•- -------------•------_..------•-•-•---^-----._.. ---.--....-•---...--.------•---•.--.•-......._......_..---•-•---•------- ^-....-..-..-----------•- ___. .._-•----....----•-•---- <br /> p <br /> Final Inspection by: _.- �r�-,�_ __... ..... date _... .�1.T "f/..__... <br /> EH 13 2h 1-68 Rev• 5m SAN JOAOUiN LOCAL HEALTH DISTRICT 8/7l1 3M <br />