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f' r <br /> FOR OFFICE'USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -G- ------ °------------------ <br /> ----------------------------------- <br /> (Complete in Triplicate) Permit No: la_-:.5_ . <br /> --------------------------_._ This Permit Expires 1 Year From Date Issued Date Issued __JO�_S�__76 <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 /> i <br /> /JOB ADDRESS/LOCATION /aa- l/" --•- '-------- ----------- CENSUS TRACT ----------- ---------- <br /> Owner's Name r- -�-----:,- -------------------------- ------ ---- - ------ ------- ------Phone I-------------------------------- <br /> Address <br /> ----------- ------------------- <br /> Address City ------ --------------------- -- <br /> Contractor's Name ------�1f. ----------------------------------License Phone' <br /> Installation will serve: Residence 0Apartment House❑ Commercial ❑Trailer Court ;[D <br /> I Motel E]Other -------------------------------------------- <br /> � ' 'y <br /> Number of living units:---/--- N'umber of bedrooms ______Garbage Grinder _�e_ Lot Size _ �___ ___ �____._..__- <br /> Water Supply: Public System and name --------------------------------- --------------------- ---------------------------------•--•------------} PriVate� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay EJPeat-[] Sandy Loam E3Clay foam ❑ <br /> Hardpan ❑ Adobe Fill Materiat ------------ If yes, type ----------------i_____:____ <br /> i <br /> p <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc.,must be plac6dAn reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200`fe ) Q <br /> I PACKAGE TREATMENT [ } SEPTIC TANK'[ ] Size.----------------------------------------------- Liquid Depth) ----------------- ` . <br /> I <br /> l9 V <br /> E Capacity ----------------- Type --------------=----- Material------- No." Compartments --------------------- <br /> Distance �to nearest: Well ------------------------------------Foundation ---------------------- Prop..Line --------------------•- <br />� y 1 '� <br /> LEACHING LINE { ] No.'.of Lines ________________________ Length of each line---_--_--------------------- Total Length -------------------------- <br /> 1 16 <br /> 'D' Box'_� .__�'�. Type Filter Material ____________________Depth Filter,Materiai --------------------------------------------- <br /> ty <br /> Distance to nearest: Well.________________________`Foundation ------------------------ Property line _____-____________-_.._. ' <br /> SEEPAGE PIT [ ] Depth ___1________________ Diameter ---------------- N6mber ------ -V_R k7Fil•led, Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size - ----- ----"--..----- <br /> Distance ,to nearest: Well ---------------------------------------Foundation -------------- ----- Prop. Line ----------------•----- <br /> REPAIR/ADDITION(Prev. SanitationPermit# ____________________________________________ Date ________- .____.__.__---__-_-____) <br /> I <br /> Tank (Specify Requirements) -------- ---------- -------- ------------------------------------- <br /> Septic + -- <br /> Disposal Field {Specify Requirements) ----_� ____ ____ c/_-_-_____ 'f ?_ �_.__-__________ <br /> 1 •-- -- ----- ,. <br /> -X-/, -- �----- -4 �' --------------------------------------------------- ---------------------- --------- ----- ---------------- <br /> ---------- -------- -------- ------------------ <br /> (Draw existing an`d required addition on reverse side) ' <br /> 1 hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations c he. 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 persion in such manner <br /> as to become subject to Workman's Compe tion laws of California." <br /> Signed ------------------- ---- --------- I ---------------------------- Owner <br /> I <br /> BY -------------------- P ` ------------------------ fiitle - y - <br /> (If of than ownrter) ++ <br /> 4 t; FOR DEPA:RTMENTUSE ONLY f JV ���r <br /> APPLICATION ACCEPTED BY __.' ��f ______ .ADAGE _P__l_ _Z�__________________ <br /> BUIWING PERMIT ISSUED ------- 1 - - __ - 'i:DATE"j _= _ <br /> ADDITIONAL COMMENTS '" (-----------------------------------------------R------- --------------------------------- `` '� €-= j------------------------------- <br /> ------------------------- -` ------------- -------------------------- = ; ---------------------- <br /> ---------------- <br /> t a=( . <br /> ----------------------- <br /> -------------------------------------'----------------------------- --------------------------- - ------------------------------------ <br /> A-k------------- �"' it------------------------------------------- -------- <br /> rNF.Z---------------------- ------ <br /> r . -------- Date <br /> Final Inspec#ion 6y: __ <br /> I SAN 4JOA-QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Rev. SM t <br />