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3 D AtIA <br /> FOR OFFICE USE- <br /> APPLICATION................ <br /> APPLICATION FOR SANITATION PERMIT <br /> ............... <br /> Permit Na. 7...77_�o <br /> ._.. <br /> (Complete II&Triplicate) <br /> -. <br /> ..............I.........I............... a -� 73 <br />........................................-_..._.._.._.... This Permit Expires 1 Year From Date Issued <br /> 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 <br /> Wl�acjyith unty Ordinance No. 549 and existing Rules and Regulations:JOB ADDRES5JLOCA71 ,?.r' -- , .. ........._.....--- CENSUS TRACT ......._-_•-•- <br /> n /' �} <br /> Ownbr's Name .... - ._-- 4+ Phone- .� 9 7¢�r1f� <br /> ............. . <br /> Address ........ _�_' .. .�- ?�D�- City . ��eG�-------------------------•----................ <br /> Contractor's Name ..............f... .-- -- -- ---- - 0"?' ............--......_•.License # _y3... Phone <br /> Installation will serve: Residence ❑Apartment House❑ CommercialTrailer Court 0 <br /> Motel C) Other ::._•-.................. <br /> _ , �` <br /> k <br /> Number of living units:..........1. Number of bedrooms ........... Garbage Grinder ------------ tot Size ............................................ <br /> Water Supply: Public System and name ........................................................._........................-.--••--.•--••-..................Privatew <br /> f <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'on,-sh6w" ing-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 /> _ <br /> PACKAGE TREATMENT ( ] SEPTIC TANK`?Qze.. '..�'r-r1C.s _..._....:.. ....._. Liquid Depth ... -�A............... <br /> Capacity( Type r...... Matsriai_._ Na, Compartments ........:.ly <br /> P S1 <br /> Distance to nearest: Well ...........,.r'�..Q--�............Foundation .....�.............. Prop. Line .........'f'.....:.W , <br /> LEACHING LINE No. of Lines ......1............... Length of ea line......... ........ <br /> Total Length ...._ -0............. <br /> 'D' Box ............ Type Filter Material . .. ... ....Depth Filter Material ....IR.,............................... <br /> Distance to nearest: Well . �.�......... Foundation ..../—A. ........ Property Line -. .� .......... <br /> SEEPAGE PIT E Depth --./,0.......... Diameter Number ............................ Rock Filled Yes No Q <br /> S'1 PQ#741 Water Table Depth ................... .Rock Size <br /> f <br /> Distance to nearest: Well Q ..Foundation ....l..O......... <br /> Prop. Line <br /> REPAIR/ADDITION{Prev. Sanitation Permit 0 ........ '............................� Date ---!�......................... <br /> Septic Tank (specify Requirements( - ` <br /> ...................• --- R-- -y... "..-.........._._... _ ? <br /> ..:....�:..: <br /> Disposal Field (Specify Requirements).. - ...I. - ............................................................. <br /> .-arwr-,rrw. <br /> ...:.................................................... -_-._---------__-----_.-_ ._...._.__..._.._.._.._._._.._._.._..._____..__.....__._____._....................._............... .._... <br /> ...... � ..._' ...:. <br /> - S w't•� � <br /> __.__................................................................-----------------------------------------..________•••__._- __.... ..................................................... <br /> 1 <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 S' an Joaquin <br /> County-Ordinances,-State Laws, and'Rulsi and Regulations of'th4'San Joaquin Lacal'Health'DiifrW Hofome owner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 _..---.... ..........L ....... ...:......... •----------------------------------- Owner <br /> By .._..-•---../-t/`�.---- . ...__.... ..................... Jitle ------�f <br /> (If of r hon owner) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY ..... ... _... .................................... DATE ... ..... ..... ..... <br /> BUILDINGPERMIT ISSUED ..-----•--------------••-•-----------•------•-• -•-•-- ----:............---•-------------- .......---....DATE _..--••--.......__...----•-----..._........ <br /> ADDITIONALCOMMENTS ..............................•.......------......................................................... -----= -••--- ............ <br /> ---•--...... <br /> ........ .... ...................................................••-•---.....................- .. <br /> ---------------------------- 1 ........................ -•---••--• --.. <br /> Final Inspection by ...........................Dote .. ._. !.. ' ._..71.x?....... <br /> .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br /> E. H.13 24 1.'68 Rev. 5M 7172-3 M <br />