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��FO OFFICE USE: <br /> � o APPLICATION FOR SANITATION PERMIT �_ 7�a <br /> ........ <br /> . ................�..' ------------ Permit Ia. . .... <br /> (Complete in Triplicate) <br /> ................................ DateIssued . . 3:.7..L. <br /> „-- :. This Permit Expires 1 Year From Date Issued <br /> f' lit <br /> Application is'hereby made to the San,Joaquin Local Health District' fol a permit.to construct and install'Vhe work herein , <br /> described. This application is ria 'n o pliance/with ounty Ordinance,No. 544 and exis 'n�,RuIa `Re ulati s: <br /> •erg <br /> JOB ADDRESS/LOCATION , :. _ CENSUS TRACT ......................... <br /> Owner's Name ...yrv�.... .... .-- -- - --------•- ................................................................................Phone ..................................... <br /> City `'..... <br /> Address .._.. 8 .. ----- ... .. �;r•�J <br /> Contractor's Name-/�{j '� License=# - �- _. one �� <br /> I Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> i <br /> Motel ❑Other ...__.. <br /> Number of living units-----�..... Number of bedrooms ..�`. ....Garbage Grinder .... ..... Lot Size ... -•-•-••• <br /> Water Supply: Public Systems and name .................. I! r� <br /> ----------------------------------- ---.__......_............------•..-------..........-----P 'vats� ♦ , <br /> r. sdip% <br /> Character of soil to a depth of 3 feet: Sand❑ .-Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay LoaIm <br /> Hardpan ❑ Adobe ❑ Fill Material ........ �If yes,type ._........._.._.._..�..._.. <br /> IPIot pion, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (Noseptic tank or seepage pit permitted if public sewer,isAavailable within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK f ] Size.... ry - Liquid Depthe <br /> _ ._ /. L1... _.... qI . ............... <br /> Capacity . Type .,. Materialr, �No. Compartments ..�. <br /> �. . T e <br />` Distance to nearest: Well .._ ...................A...Foundation .. . . Prop. Line .b.t ............ <br /> 'r X 0....---- <br /> LEACHING LINE [ J No.: of Lines ..----v ,...•_... .... Length,of.each .line......re............... Total Length '111_16.P....... <br /> I: 'D' Box ...I...... Type Filter Material ...... '. , . .-- Depth Filter Material ...A�.... ...................... <br /> Distance to nearest: Well .:........... Foundatlan .... Property Ling <br /> [ j Depth ./�. 1� 1.�D]ameter Nuniiier .---.--' ...... Rock Filled .'Yes No ❑ <br /> Water TablerDepth .... .............. {.. ... Rock Size .. ._-.---------- <br /> Distance to nearest: Well ------ .............Foundation .................... Prop. Line ....................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ............................. I <br /> ' Septic Tank {Specify Requirements} ...................-.........I........ ............. . .... . .......... �_........ <br /> •` =... <br /> _. <br /> DisposalField {Specify Requirements} ........................................ •-••--------•-----...................................................................... <br /> s <br /> ..............•• -----............._..--•--•---..................................................... - -._......-------•--•--- <br /> --•-•--- - ....... .. ----- --.. <br /> IDraw existing and required addition on reverse side} <br /> I ' <br /> i 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. Flem� owner or Iicen'-h.,. Y <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 /> ` __. Owner �~ <br /> Signed •--... ---------------- y <br /> By .................. ._................. Title _... -"_._..._.._...........- <br /> I f oth r&aokwner) •<� <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> u� <br /> i; APPLICATION ACCEPTED BY .-...-.._----•------------.................................... DATE .. .... 1.�.=� ...::-- -----• <br /> BUILDING PERMIT ISSUED -•-......I ..... .............. ..... �I _ . . <br /> --•-.D <br /> ADDITIONAL COMMENTS " c _" ATI: ..............��...........-------__- .. . <br /> ....... �=U f-� r�ll?r .. ... �l�R -...... ......................:..........•------.......... <br /> !}®lY1f2... a...........Ti�. ................:4. <br /> ........................................................ ---............ . <br /> . . - ......•......... . ..........•-...D. _.. . <br /> Final Inspection by: .... .. ............................................................ ate ...... . <br /> .. .�_. <br /> j ._ <br /> 4. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 13-24 7/723 ,14 <br /> F. M. 1-'68 Rev. 5M -•- - —--__ - <br />