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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT /Od9 <br /> Permit No. . --- -- <br /> ------------------ - ;Complete in Triplicate] --.� <br /> ------------------- ----------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued-------------- <br /> Application is hereby made tot a San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This applicat'o is <br /> ade in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDR€ T ------109-5Q--Na---West--Lane-------------Lodi,,---Ca- ----- i <br /> CENSUS TRACT -------------------------- <br /> y erald C. Wolf/Charles A. Sherrow 368-7566 <br /> Owner ame ----------------------------------------------------------------- ----------------------Phone ------------------------------------ <br /> --- <br /> Address -----------------10950 N. West---Lane ---------------------_--.• Cit Lodi s Calif. <br /> --- --- <br /> -- ---------- --------- <br /> Contractor's Name -Uxe -------•-------------------------------------------------------- -------License # ------ - ------ Phone --------=---------------.-...., <br /> Installation will serve: Residence ❑Apartment House[] Commercial X]Trailer Court ;❑ <br /> Motel ❑Other ----------------------------------------•--- Q <br /> Number of living units_____________ 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'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan [5d 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 <br /> l 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------------------------------ Tota! Length ------------ ---------------- <br /> ' <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------.- <br /> Distance to nearest: Well ________________________ Foundation ------.-------------_--- Property Line. ----------...-_......... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line -------............... <br /> REPAIR/ADDITION{Prey. Sanitation Permit# __________________________________________ Date`_______________-___.___.___----_--) a <br /> SepticTank (Specify Requirements) ------------------- -------------------- -----------------------------------------=------------------------ ----------------------------- <br /> Disposal Field (Specify Requirements) ------Add---5Q1----lea-ch__I:Ln.S__arid_-O.Ae__2._,x --sump----------------------------- <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 R_egu-lotions of.the San Joaquin Local Health District. Mome owner or licen- <br /> sed agents signature certifies the following: - �'� <br /> "I certify that in t e performa <br /> nce of the' ark for which this permit is issued, I;shall not employ any person in such manner <br /> as to becomes ject t Workman's �ompensati.on Incas of Cafifornia." <br /> Signed -- '. ....... <br /> - Owner <br /> By - ------------------------------------ Title <br /> ------------------------------------------ -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY `1 <br /> APPLICATION ACCEPTED BY _ ___________ __ ___ - ' ----------. DATE I/-__ _-T.__---_ <br /> BUILDING PERMIT ISSUED ----------------� == = ===' -DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------ ------------- <br /> ---------- -_ - <br /> ;.------------- --------- ------------ - ----------------------------------------------------------------- -- ------- <br /> ------------------------------------ --------------- <br /> 0 <br /> --------------------------------------- <br /> 0 --------------------- <br /> ------------------ - ------------------------------------ ---------------------------------------- -- -------------- <br /> FinalInspection by: ✓ --- - ---------------------- ------------------ -------------------------------Dater --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M .,__o <br />