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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- --- ------------------------------------------ ��- Permit No. <br /> (Complete in Triplicate) <br /> ----------------------------" 1 <br /> f� Date issued _---.-���___�P.9 <br /> -----------------------------___ ___ ____�✓___________ This Permit Expires 1 Year From Date 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 .__Z J6Q--__ --______40-JJ <br /> -- - ----------- —1?---------------------CENSUS TRACT - -------------------- <br /> Owner's <br /> _----.4_----- <br /> Owner's Name --------,�1_NoR-]>......... -0?0-R-11A------------------------ ----------------(- -----------------Phone ------------------------------------ <br /> Address -------------5XQ----- Q1A l�!_�fZ---------------------- ----------------­---- <br /> ---------------- --. City ---------13_1_pa-4------------------------------------------------- <br /> Contractor's Name ------4 V1-t4 -------------------- --------------- --------License # ------------------------ Phone ------------_----_-_----- <br /> Installation will serve: Residence partment House❑ Commercial []Trailer Court i❑ <br /> NumbMotel F1 Other -------------------------------------------- <br /> Number of living units:-----I-_-- Number of bedrooms ---3------Garbage Grinder A1Q_-- Lot Size —4-CRE-78-67E.- <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 ❑ <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.) 1^1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK:[ ] Size----------------------------------- ------ Liquid Depth -------------------------- 0\ <br /> Capacity ------------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well -------------------_-_-------..--_-Foundation ---------------------- Prop. Line ................ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _-_--_.__._-.-.._----------- <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -_-__--_-___-.__-__.__._-___-..------- ---- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ____-__--- _----_-_----------------Foundation -------------------- Prop. Line ..........,----------- <br /> REPAIR/ADDITION <br /> - -__REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____---.----_---_--._________ --) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------•----------------------------- <br /> Disposal Field (Specify Requirements) .--.-4PP - � H- --/-) ----------- ...... l! c- <br /> ------- t <br /> OX---------------' '1-----4-F-76<J_-}------�1 n(�----------�--------yx �-X----/Z--1----------- <br /> ----------------1>1T`------------------- ----------------------------------------------------------------------------------------------------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to bec/on ct ibieto Wo an's Co pensati.on laws of California." <br /> Signed I1�/���2i�---- ��� Owner <br /> By --------------------------------------------------------- ------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----41------- t R`©'-------------------------------------------------------------- DATE - <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------ ----------------------------- DATE ---------------------------- - <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------..------------------------------------------------------------------------------------------- <br /> --------------------------------------- ----- - --------- ---- <br /> ---------- - ----- --- --- ------------------------------------------------------------------------------------------------------------- <br /> - --------------------- - ------- -- - - ---------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ---- -- ------------------- - ------ ----- - -- -------- ----------------------------------------------------- <br /> Final Inspecti b ------------- --------------------Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />