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F <br /> FOR OFFICE USE: APPLIC�I�IOIV- AOR SANITATION'PERMIT <br /> ---------------�� 0-------- X7 7 d Permit No. __.72_2'119__. <br /> Complete in Triplicate) <br /> --------------------------------------------------------- This Permit Expires I 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 compliance with County Ordinance N-0 9 4Fttid existing Rules and Regulations: <br /> JOB ADDRESS/LOCATO tJ �'"'r , c.�,�i --P- rte--- ----•---•-----CENSUS TRACT -------------------------- <br /> --- <br /> Name --- - - ---------Phone3-�_-O -.- <br /> ------- -------------------------- --- <br /> Address ---- l - City <br /> �- -�ri✓--- <br /> Contractor's Name -- * --------------------------License # ,� _a�// Phone 6� D <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:------J---- Number of bedrooms ___/------Garbage Grinder ------------ Lot Size .......?­_ �----------------- <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private'K <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom -❑ Clay Loam ❑ <br /> Hardpan ❑ Aclobe'l>6 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 -------------------------- o� <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 ----_-----_-_-.-_._---- <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(Prev. Sanitation Pe74pa-e-9 <br /> it# --------------------------------------------� -- Date ---------------__-------------- <br /> 1 <br /> Septic Tank (Specify Requirements) -------_ --i --- R..- - <br /> Disposal Field (Specify Requirements) ------------------------I---------•----- <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 /> ------------------------------------------------ <br /> {If other t an owner} <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEP ED BY ------` ------------------------------------------------------- DATE -----�� ,���- ------------ <br /> ---- --- - - - <br /> BUILDING PERMIT ISSUED -------- -- - -- ---- ---- - ---- ---- ------------------- ----------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------ -- --- --- - ------- --- ---- ---------------------------------------------------------------- ---- --------------------------------------- <br /> -------------------------------------------------------------------------------- <br /> ----------------------------------------- - ---- - ----- - ------------------------------------------------------------------------------------------------------------------------------=------- <br /> Final Inspection by: ----- - - - ------------------------------Datet9 <br /> ;�JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />