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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> 4�1� Permit No <br /> � <br /> J r � (Complete in Triplicate) ' <br /> Date Issued <br /> -------------------------------------- This Permit Expires t Year From Date issued <br /> r <br /> Application is hereby made to the San Joaquin Local Health Distri&i/for a permits-t oconstruct and install the work herein <br /> Regulations- <br /> described. This application is madeincompliance witfiCounty Ordinance No. 54. and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . 1-- S_ - ----------- -- - --- -------- ------- CENSUS TRACT ---------�-•-------- <br /> _. . <br /> Owner's Name / �'LJ�, ---------•- ------ ----Phone � - --- ------- <br /> Address ------- ` w ---v-- -- --•- . City - ------- - <br /> r_� e <br /> Contractor's Name 1 -� -------- .License #IQeS-l' one <br /> Ph X66 ��'°7 <br /> Installation will serves -� Residence Apartment H61-4 O'Commercial"[]Trailer Court";❑ "" <br /> z `•� �` Motel ❑Others?------------------------------------------ <br /> •€�. <br /> � X/s------ <br /> Number of living units.----/_____ Nuiriber...of bedrooms -3----Garbage Grinder _' • L`t,Size.,______-'_____ __ <br /> Water Supply: Public System and name -- ---------- --------------------------- -------- WWW - "W------------..._-----•: Private [ICharacter of soil to a depth of 3 feef"-� (Sa d'❑ Silt,E ''Clay)(] -Peot El Sandy Loam ❑ Clay LoamZ] <br /> • F�r L am' M f jV <br /> Hardpan ❑ Adobe Fill Material __ __ If Yes,type ---------------I------------ <br /> -m:. 4 <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 /> Am 6 <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size---------------------------- --------- �Liquid Depth --------------• ------- --- <br /> Capacity '==;TyypeF---------------- - <br /> Material---------------------- No. Compartments ------------------- <br /> Distance to nearest: Well -----------------------------------Foundation ---------------------- Prop. Line ---------..-------•---. <br /> k ----------•-- <br /> i LEACHING LINE No. fLites - Length <br /> ength of each line----------------=----------- Total Lengt <br /> DBox _:____ TYae Filter Material --------------------Depth Filter Material --------- -- ____Distance <br /> to nearest: Well_________________________ Foundation --------- ------------- Property Line __-__._.------------..-- <br /> SEEPAGE PIT [ ] Depth _ --------------- <br /> Diameter ________________ Number ---------------------------- Rock Filled Yes '[] No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> t <br /> _� Foundation Prop. Line <br /> Distance to nearest:"�1Nell _______:____ _._ __ ------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------"--------•-------•------1 <br /> Septic Tank (Specify Requirements) --.---------- ` f y' `------------ <br /> ------------- <br /> --------------------------- � /] i� <br /> Disposal Field (Specify Requirements) . ___ <br /> r �#Y------- � --_ ' -�-------- <br /> ---- ---------- ----- ! <br /> - r- ---------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applic'tilion and that the work wilE bedone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rulee andloRegulations of the. San Joaquin Local Health District. Home owner or liten- <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 /> f <br /> 1 9 <br /> Signed ------------------------------ - -- i Owner <br /> --------- - ------------- <br /> 1 '------------------- Title - ---- j <br /> Wil/ r <br /> (If other tha ner) k <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY'------- -- f T -- ---------- <br /> ------------------- <br /> -------------- <br /> -------- <br /> BUILDING PERMIT ISSUED - DATE <br /> ----------- - <br /> ADDITIONALCOMMENTS --------------------------------------------- -`------------------------------------------------------------------- ------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - --------------------- ----------------------------------------------------------------------------- <br /> ------------------------------------------------- --- ------------ -�-----�--_-------�----r- -------------------------------------------- <br /> - ----- ------- <br /> Y-- <br /> Final Inspection by Date <br /> t- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />