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r S <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> -------�-�3'-;� ---------------------------- - .T�-llfs� <br /> --- ------�1�----------------------------I-------------- (Complete in Triplicate) <br /> Date Issued'p��.,3©._ <br /> ------- ------------------------- ----------------------- This Permit Expires 1 Year From Date Issued <br /> .Tr <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 with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION R-;F"_ �C- <br /> r . pfd ''=- �� y*�CENSUS TRACT -------------------------- <br /> Owner's Name 1.. ..:. ' -- <br /> ��-�- ---�-�f��,. ��-�"�--��'�- -��,f----------------------------------=----------- ----:-Phone ------------------------------------ <br /> Address -------b� - --------------------------------------------------------------------- City size/ VIKI-1---------------------------------- <br /> Contractor's Name .-------. -_. f {_-- -- -- ------------------------------.License _ Phone ' <br /> Installation will serve: Residence Apartment House[] Commercial:❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of lung units:'=t.._ _ [ umber of bedrooms Garbage Grinder / -- Lot Size _ . ---------------- <br /> � E <br /> Water Supply: Public System and name ` ~ I r`-----------------------------------------------------Private, ` i <br /> Charact#of soil to a depth of 3 ffk�e.et-1 Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> # Haldpan ❑ Adobe)K Fill Material,,--x_------ If yes, type -------------- ------------ <br /> f <br /> (Plot plan, showing size of I t' Iloc'tion of system in relation to wells, buildings, etc. must be placed on reverse side.) , <br /> NEW INSTALLATION: (Notseptic tank or seepage pit permitted if public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT .[.7 .SEPTIC TANK[ ] Size------------t------=---------------------------- Liquid .Depth _------------------------- <br /> Capa itY --- ------- ------ Type -------------------- Matirial---------------------- No. Compartments <br /> Distance to nearest. Well .._.._� _-:..__Foundation __-.__.__._._.._.._ Prop. Line .............:........ I <br /> LEACHING LINE V[ I No. of Lines ------------------------ Length of each 'line---------------------------- Total Length ,.------._ <br /> ',D' BoxI..--;..-.--- Type Filter Material -------------- <br /> ------------ -----Depth Filter Material ------------------------------------- ------ <br /> 'Distanc6 to' nearest: Well .----------- I.._ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth k .-...- _..._�.Diameter.-.._--_�--._--,Number ___________________________ Rock Filled Yes ❑ No <br /> O <br /> Water,Table: Depth., Rock Size <br /> --------------- -------------------------------- <br /> Distancetoto nearest: Well -__`-'__- _________--------------___Foundation -------------------- Prop. Line _......._............ � <br /> REPAIR/ADDITION(Prev. Sanitation.Permit# ------------------------------------- ---~ <br /> Date ....._.._.._......._A..__.._._._. <br /> --- <br /> , FA - � r Septic Tank (Specify Requirement] tet,. A'Disposal field (Specify Requirements} �� -- <br /> C `------------ -- - _ -------------------------•---------------------------- <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, land Rules and Regulations of the San Joaquin Local Health District. Home owner or liven- <br /> sed agents signature certifies#Fie-following: <br /> "I certify that in the performance of'We 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 /> �� � ` = <br /> BY �9� a Title Zz� <br /> -------------------- <br /> (If of than owner] <br /> FOR DEPARTMENT USE ONLY/ � <br /> APPLICATION ACCEPTED BY ---------- _ - ----- --------'�f------------ ------ DATE ------1� .34 ......------. <br /> -- -------------- --------------------------- -- <br /> BUILDING PERMIT ISSUED - --DATE -------- <br /> - ---=------- - - <br /> ADDITIONAL COMMENTS �� °, 7� ����•-----------£�----------------------'------------------------------- ------- ------------ "------•-- ------ <br /> ---------------------------------- ------�`------------- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> fi <br /> ------ <br /> -- l - - - <br /> Final Inspection by: ---------------J--=-- - <br /> ----------------------------------- --- <br /> � ' ---- - - -----------------------------------------------------------------=----------------- .Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9_ yL]-'68 Rev .5M <br />