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FOR OFFICE USE: APPLICATION-;�EOR JANITATION PERMIT <br /> Permit No.. <br /> I A f (Complete in Triplicate) <br /> -------------- s-s-7i <br /> Date Issued'-------------------- <br /> This Permit Expires 1 Year From Date Issued <br /> " � —Tom:..--�-�---�. - -. .t,,,. �•.:�•_ —.._ _— •. �-.��.,-��--� <br /> Application is hereby made o the San Joaquin Local Health District for a permit to construct and install the- workherein <br /> described. Th} licati s made in capnpliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> 42 0 <br /> JOB ADDReSS/LOC TION ._ __51 ---Q.1'__.lryl_ ^Qn.l /_ -- .�D --'-/Il _ :_ CIIJR�ACT --------------•----------- <br /> rr t --------------Phone---------------------------- <br /> Owner's Name ----- --- ------ 1= ------------•---- -------=-•--- <br /> Address r C + ? ------------------ City ----------------- <br /> t . s�cjC3 Z-------------------- <br /> L/� <br /> Contractor's Name --------------------- - License #v / Phone <br /> --- <br /> Installation will serve: Residence partmen't House'❑ Commercial ❑Trailer Court f❑ <br /> (Motel ❑,Other ---=---------------------------------------- <br /> Number of living units:----J---- Number of bedrooms ___-__Garbage Grinder- Lot Size ---------------- <br /> Y - ----------- -- <br /> r LP c, ----------- ---- -------------- -•---------•-----Private ❑ <br /> Water Supply: Public System and name ___._ _ _- <br /> Character of soil to a depth of 3 feet- Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill 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 /> 7 SEPTIC TANK seepage pit permitted if public sewer is available within 200pfeet,) <br /> ,r Si e---- Li uid Depth <br /> __-- --- -� <br /> NEW INSTALLATION: {No septic ta;k or - - � <br /> PACKAGE TREATMENT f ] . _,Qp /� �r 01 \ <br /> Capacity �� Type <br /> r/�C.LC� f_ Material :IVo.f Compartments -------------------- <br /> Distance <br /> -------J• ------- <br /> Distance to nedresf: ,Well __.__-_1----' ~-------------Foundation __ �___---- ,____ Prop. Line,_ _____:_.--__-- <br /> F I � � r <br /> / :-Tot al Length- -- .......... <br /> LEACHING LINE No. of Lines __ -----r----------- Length of each line-Al_______________ !{ <br /> YP _ Depth Filter Material _f-�----.._-- <br /> 'D' Box•____._V--- Type Filter Material -- l <br /> Distance to nearest: Well ---------— Foundation ,1 - ----_- Property Line <br /> -- <br /> SEEPAGE PIT Depth _-- l-------- Diameter _ -fr Number ------ _________________ Rock Filled Yes [ iVo <br /> Water Table Pepfih =, _ -- --- ----- Rock Size _ _ <br /> Distance to nearest: Well --------- '�------------------------•-Foundation -��------.---- Prop. Line= ---------..... .•. <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -'-------------------------- -------------- Date -------------------'---------------) <br /> Septic Tank (Specify Requirements)'------------ ------ --------------- <br /> --'--------------------------------------------'--------------------------•---- '------•-------------- <br /> Disposal Field (Specify Requirements) ----- -------------------- ------- -----------------------------•--------------------------------------------- ----------------------- <br /> It. <br /> ___________ ` ________________________________________________________________________'.-__-__-_-_.-___ <br /> _______________________ --------------------------------------------------- <br /> ___-__._-__._ -__ -_------___.________-____-_-----____---_-___----_ _ - <br /> _ <br /> (Draw existing and required addition ori 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 /> ----------- ---------------//---------- <br /> By - -------------------------------- -------- <br /> G Title lel' --------'-; --------------- <br /> (If other than n r) k <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ - -- - - - - - ----------------------------------------------- DATE ---- <br /> BUILDING PERMIT ISSUED ------- --------- ----- 1r; - <br /> --------------------------------- -------------DATE --- ---------------- ------------------ <br /> ADDITIONALCOMMENT ---- -- ----------=-------------------------------------------- --------- ----------------- <br /> ---- ---------- - - - - ---------------------- -------------------------------------------------------- ------------------ <br /> --- --- ------------- --------------- --- - - ---------- -- --- -------------------------------------------------------------------------------------- -- <br /> ----------------------------------- ------ - ----------------------------------------------------------------- ---------- ---- - <br /> Final Inspection by: -- ------ - -- Date <br /> AN JOAQUIN LOCAL HEALTH DISTRICT � ' <br /> E. H. 9 1-'b8 Rev. 5M. �, <br />