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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- -----------------•- Permit Na <br /> ----------I----- ------------ ----------I-------------- <br /> (Complete in Triplicate) <br /> Date Issued <br /> _ ---------------------------------------------------- This Permit Expires 1 Year From bate 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 No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION .......0e-------- -_k[A------------------ `� <br /> --------------- CENSUS TRACT ------------ -------- <br /> Owner's Name Are- ------ --.----- ------ ----------------------------Phone ---------------------------------- <br /> ___________If IF ��1!l\l'�1K1-SCI --- - <br /> Address ------.1,0131Jf------ -----MAI-Al------ - Cowsr- co, City /�' r -- ----------- <br /> d <br /> Contractor's Name --- W,?! -----/ //,CGiI ----------------------------------------------License # ----- -- --------------- Phone A?3--- (334 <br /> Installation will serve: Residence [Apartment House-[] Commercial ❑Trailer Court ;[] <br /> Motel ❑ Other ---------------------------------------- -- <br /> Number of living units:-----!------ Number of bedrooms __ _-_-Garbage Grinder ------------ Lot Size ---_`----12_4�/--r_______ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam g? <br /> Hardpan ❑ 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,) 10, -4 <br /> PACKAGE TREATMENT ( ] SEPTIC TANK![ Size-e7- -------�__-__.--_- --------- Liquid Depth -_--_-5Y______________ 00 <br /> Capacity _-APG'V______ Type ----------- ---------- No. Compartments ----a------------- _9 <br /> Distance to nearest: Well -------- .........................Foundation --------- Prop. Line __„ .............. 6 <br /> LEACHING LINE No. of Lines ____ ! <br /> [� ,✓_______________ Length of each line_____ U._____:__._____ Total Length _ fl_f_0___.._. <br /> 'D' Box -----/----- Type Filter Material ��__,a___,'.7__Depth Filter Material--_-/,5-------------------�_____-____._ <br /> Distance to nearest: Well ----6-0..________ Foundation __�3_�_____-___ Property Line ____.�_.__�..... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ---------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well _---------------------------------------Foundation -------------------- Prop. Line .___.._.__.... ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- --------------------------_ ---------------- -- ---- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- ------ l <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 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 bec subject tobbWork an's Compensation laws of California." <br /> Signed . 1r-1--- m-S7 -----SCJ s------------------ Owner <br /> By ----- ----- ---------------- Title ------------------- <br /> - - ---------------------------------------------------- <br /> (If of r than owner) <br /> bb FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------------------------------- DATE ------------ <br /> BUILDINGPERMIT ISSUED ------------- ------------------------------------------------------------------- -----------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS .---------7/--------------------------------------- - ----------------------------------------------------------------------------- -------- <br /> ----------------------------------------- ---r <br /> ------ -- -------- --------j- ----------------------------------------- ----------------- <br /> ------ -- ---------------------- - <br /> T <br /> --------------------- --------------- --- '- - - -- <br /> - - - — <br /> Final Inspection Y: -------- - ------- --r--- ----- --------------------------------Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />